The Laurels Of Bon Air

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to maintain residents' highest level of well-being for two of 43 residents in the survey sample, Residents #104 and #133. The findings include: 1. For Resident #104 (R104), the facility staff failed to initiate and implement treatment for toe wounds that were identified on 6/12/24. A review of R104's clinical record revealed a note signed by the wound care physician on 6/12/24 that documented the resident presented with a wound on the right first toe that measured 1.5 x 0.6 x 0.3 cm (centimeters) and a wound on the left first toe that measured 1.5 x 0.5 x 0.2 cm. The note further document dressing treatment plans to apply a primary dressing of Xeroform gauze three times per week. Further review of R104's clinical record (including physician's orders, the June 2024 treatment administration record, and nurses' notes) failed to reveal any physician's…

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

Based on observation, family interview, facility document review, and clinical record review, the facility staff failed to provide foot care for one of 43 residents in the survey sample, Resident #27. The findings include: For Resident #27 (R27), the facility staff failed to trim the resident's toenails. On 6/24/24 at 1:07 p.m., R27 was observed sitting in a chair in his room. R27was unable to carry on a coherent conversation. R27's daughter was sitting in the room, and expressed concerns about the length of the resident's toenails. R27's daughter removed the shoe and sock from the resident's left foot. The resident's great toe, second toe, and third toenails all extended greater than one inch past the tip of the resident's toes. A review of R27's clinical record revealed no documentation of diagnoses of diabetes or other conditions that would indicate a lack of blood flow to the feet. This review also revealed no orders for foot care, and no documentation of offering for the resident to be sent out for a podiatry consultation. On 6/26/24 at 9:10 a.m., 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, staff interview, facility document review, and clinical record review, the facility staff failed to provide a safe environment for three of 43 residents in the survey sample, Residents #56, #22, and #19. The findings include: 1. For Residents #56 (R56) and #123 (R123), the facility staff failed to store portable oxygen tanks safely in the residents' room. On 6/24/24 at 12:07 p.m. and 6/25/24 at 8:17 a.m., observations were made in the room shared by R56 and R123. Two freestanding portable oxygen tanks were observed along the wall. Neither tank was secured in a rolling cart or any other device. One tank measured 1000 psi (pounds per square inch) of oxygen; the second tank measured just under 1000 psi. On 6/26/24 at 9:10 a.m., LPN (licensed practical nurse) #3 was interviewed. She stated portable oxygen tanks should always be secured in a secure storage rack in the supply room, or on rolling carts if they are any other place in the facility. She stated portable tanks should never be unsecured at all. She stated: Anything could happen. It could fall over, or turn…

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 maintain a Foley catheter in a sanitary manner for one of 43 residents in the survey sample; Resident #97. The findings include: On 6/25/24 at 10:21 AM, Resident #97 was observed in her room up in the wheelchair. The Foley catheter bag was hanging under the wheelchair, with the bag mostly laying on the floor. On 6/25/24 at 10:32 AM Resident #97 was observed sitting in the doorway just outside of her room asking a staff member for water. The Foley bag was still noted to be dragging the floor. The staff member did not address the Foley bag on the floor. On 6/25/24 at 10:37 AM, Resident #97 was back in her room. Upon passing by the resident's room, it was noted that the resident was sitting in her wheelchair approximately three quarters of the way to the opposite side of the room from the door, with the Foley catheter bag laying on the floor several feet behind her wheelchair, with the tubing fully stretched from the bag to the resident. 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 staff interview, facility document review, and clinical record review, the facility staff failed to provide colostomy care and services for one of 43 residents in the survey sample, Resident #127. The findings include: For Resident #127 (R127), the facility staff failed to obtain physician's orders and provide care for the resident's colostomy (1). A review of R127's clinical record revealed a nurse's note dated 6/11/24 that documented the resident was admitted with a colostomy. A review of R127's June 2024 physician's orders failed to reveal any orders regarding the resident's colostomy. Further review of R127's clinical record (including the June 2024 treatment administration record and June 2024 nurses' notes) failed to reveal colostomy care was provided (except for a nurse's note dated 6/14/24 that documented the colostomy bag was intact and changed on 6/13/24, and a nurse's note dated 6/17/24 that documented the colostomy bag was intact and emptied once during that shift). On 6/26/24 at 10:03 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for one of 43 residents in the survey sample, Resident #76. The findings include: For Resident #76 (R76), the facility staff failed to administer oxygen at the physician prescribed rate of two liters per minute. A review of R76's clinical record revealed a Brief Interview for Mental Status assessment dated [DATE] that documented the resident was cognitively intact, scoring a 15 out of 15. Further review of R76's clinical record revealed a physician's order dated 6/24/24 for continuous oxygen at two liters per minute. On 6/24/24 at 3:13 p.m., R76 was observed receiving oxygen via nasal cannula at a rate between three and half and four liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned between the three and half and four-liter lines. On 6/25/24 at 10:46 a.m., R76 was observed…

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

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure that a current evaluation and consent, including risks and benefits, were in place prior to implementing side rails, for three of 43 residents in the survey sample; Residents #22, #19 and #86. The findings include: 1. For Resident #22, the facility staff failed to ensure that a side rail evaluation and consent, to include risks and benefits, that determined side rails were needed, was completed prior to implementing side rails. On 6/24/24 at 12:42 PM and at 2:54 PM, 6/25/24 at 10:17 AM and on 6/27/24 at 9:13 AM, Resident #22 was observed in bed. Quarter length sized side rails were observed on both sides of the bed in the upright position. A review of the clinical record revealed a Physical Device Evaluation dated 12/18/22. This document documented that the type of safety device to be used was Bed against the wall and the reason was for Safety awareness. The options for any type of side rails were not checked. A review of the Siderail…

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, staff interview and facility document review it was determined that the facility staff failed to ensure that pharmacy recommendations were reviewed and implemented in a timely manner for three of 43 residents in the survey sample, Resident #26, Resident #75 and Resident #29. The findings include: 1. For Resident #26 (R26), the facility staff failed to ensure pharmacy recommendations were reviewed and implemented as needed for the 9/2/2023, 11/3/2023 and 12/5/2023 monthly medication regimen reviews. A review of the monthly pharmacy medication regimen reviews for R26 documented monthly consultations documented in progress notes. The progress notes dated 9/2/2023, 11/3/2023 and 12/5/2023 all documented .See report for any noted irregularities and/or recommendations . On 6/26/2024 at approximately 10:27 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of the pharmacy recommendations with physician and/or facility response for the dates listed above. On 6/26/2024 at approximately 2:25 p.m., ASM #2, 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, clinical record review and facility document review, it was determined that the facility staff failed to ensure that one of 43 residents was free of unnecessary medication; Resident #22. The findings include: For Resident #22, the facility staff failed to evidence that consistent ongoing monitoring for the use of an anticoagulant medication was conducted. A review of the clinical record revealed a physician's order dated 2/25/24 for Eliquis (1) Oral Tablet 2.5 MG (milligrams) (Apixaban) Give 1 tablet by mouth two times a day for a fib (atrial fibrillation). There were no orders for consistent (daily or every shift) monitoring of the use of this medication. A review of the comprehensive care plan revealed one dated 11/23/22 for Administer medication as ordered. Observe for ineffectiveness and side effects. A second intervention dated 11/23/22 documented, (Resident #22) is at risk for abnormal bleeding/bruising r/t (related to) Medication use: -Anticoagulant. Dx (diagnosis) A Fib. An intervention dated 11/23/22 documented, Observe and report to physician PRN…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate medical record for 1 of 43 residents in the survey sample, Resident #323. The findings include: For Resident #323 (R323), the facility staff failed to maintain a complete and accurate medical record documenting the reason for transfer to the emergency room on 4/4/2024. Review of R323's progress notes revealed the following: - 4/4/2024 08:37 (8:37 a.m.) Nurses Notes. Note Text: Res. (resident) left via ambulance with emergency services, res. was alert at time of departure, res. POA (power of attorney) called and notified of res. transfer to hospital, res. POA to meet res. at hospital. - 4/4/2024 14:15 (2:15 p.m.) Nurses Notes. Note Text: Writer called [Name of hospital] and was notified that res. was admitted to ICU (intensive care unit). Review of clinical record failed to evidence documentation regarding a change in condition or the reason why R323…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to follow infection control procedures for one of 43 residents in the survey sample, Resident #93. The findings include: For Resident #93 (R93), the facility staff failed to use proper hand hygiene to prevent the spread of infection. On 6/24/24 at 2:33 p.m., CNA (certified nursing assistant) #2 was observed entering R93's room. R93's door had a sign indicating anyone entering the room should observe contact precautions (1). Prior to entering R93's room, CNA #2 donned gloves; she did not put on an isolation gown. CNA #2 assisted the resident to transfer to the wheelchair, and pushed the resident into the bathroom. CNA #2 closed the resident's bathroom door, removed her gloves, and left R93's room without washing her hands. She then entered the room of another resident and closed the door. On 6/24/24 at 2:44 p.m., CNA #2 was interviewed. She stated she did not wear an isolation gown because she merely assisted the resident into the wheelchair, and pushed her into 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 clinical record review, staff interview and facility document review, and it was determined that the facility staff failed to notify the physician that a resident's medications were not administered for one of 52 residents in the survey sample, Resident #2 (R2). The findings include: For (R2), the facility staff failed to notify the physician that the physician ordered antibiotic, ceftriaxone [1] was not administered on 10/27/2022, 10/28/2022, 10/31/2022, 11/01/2022 and on 11/02/2022 and vancomycin [2] was not administered on 10/18/2022, 10/19/2022 and 10/28/2022. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 09/20/2022, the resident scored 9 (nine) out of 15 on the BIMS (brief interview for mental status), indicating (R2) was moderately impaired of cognition for making daily decisions. The physician's orders for (R2) documented in part, Ceftriaxone Sodium Solution Reconstituted 1 (one GM (gram). Inject 1 gram intramuscularly every 12 hours for infection for 5 (five) days. Start Date: 10/27/2022. D/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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that the RP (responsible party) and/or Long Term Care Ombudsman was notified of a transfer to the hospital for four out of 52 residents in the survey sample; Residents # 95, #15, #31 and #81. The findings include: 1. The facility staff failed to evidence written RP (responsible party) and/or ombudsman notification at the time of discharge for Resident #95. Resident #95 was transferred to the hospital on 9/22/22. Resident #95 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: anemia, hypertension, and malnutrition. The resident was transferred to the hospital on 9/22/22. A request for written RP or ombudsman notification for the resident was made on 11/3/22 at 10:00 AM. An interview was conducted on 11/3/22 at 11:15 AM, with RN (registered nurse) #2. When asked what notification is provided when the resident is sent 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 staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notifications were provided to four out of 52 residents in the survey sample that were transferred to the hospital; Residents # 95, #15, #31 and #81. The findings include: 1. The facility staff failed to evidence bed hold notification was provided at the time of transfer to Resident #95 and/or resident responsible party. Resident #95 was transferred to the hospital on 9/22/22. Resident #95 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: anemia, hypertension, and malnutrition. The most recent MDS (minimum data set) assessment, a 5-day Medicare assessment, with an ARD (assessment reference date) of 10/10/22, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the comprehensive care plan with a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, responsible party interview, staff interview, facility document review, clinical record review and in the course of complaint investigations, the facility staff failed to provide residents with a summary of the baseline care plan for five of 52 residents in the survey sample, Residents #162, #309, #72, #111 and #109. The findings include: 1. For Resident #162 (R162), the facility staff failed to provide the responsible party with a summary of the baseline care plan. R162 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/29/2022, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. The 72 Hour admission Conference dated 6/26/2022 for R162 failed to evidence the responsible party being provided a summary of the baseline care plan. A review of R162's clinical 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. For Resident #19 (R19), the facility staff failed to implement the comprehensive care plan to provide pressure ulcer treatments as ordered. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/1/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. Section M (skin condition) of the assessment documented R19 having a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. It further documented R19 at risk of developing pressure ulcer/injuries and not having any unhealed pressure ulcer/injuries. The comprehensive care plan for R19 documented in part, [R19] has the potential for skin breakdown and pressure ulcers related to impaired mobility and urine incontinence. Actual skin impairment: wound to sacrum and blisters to left upper thigh. Date Initiated: 08/08/2019; Revision on: 08/25/2022. Under Interventions it…

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, clinical record review and in the course of a complaint investigation, the facility staff failed to follow professional standards of care for quality resident care for two of 52 residents in the survey sample, Resident #162 and Resident #2. The findings include: 1. For Resident #162 (R162), the facility staff failed to timely act upon critical lab results reported to the facility on 7/8/2022. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/29/2022, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. Section I documented R162 having an active diagnosis of anemia. Section O documented R162 receiving transfusions while not a resident of the facility and within the last 14 days. The physician orders for R162 documented in part, - CBC (complete blood count) with diff (differential) and BMP (basic metabolic panel) in the next 3 days one time only for anemia for 3 days.…

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, facility document review, and clinical record review, it was determined the facility staff failed to monitor a physician ordered fluid restriction for one of 52 residents in the survey sample, Resident #6 (R6). The findings include: For Resident #6 the facility staff failed to evidence documentation of the monitoring of physician ordered fluid restriction. There was no documentation to show the total amount of fluids the resident had daily and no documented review if the fluids amounts were within the physician ordered fluid restriction. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 10/4/2022, coded the resident as scoring a 15 out of 15, indicating the resident is not cognitively impaired for making daily decisions. R6 has a diagnosis of congestive heart failure (CHF). Observation was made on 10/31/2022 at 2:31 p.m. The resident was sitting in their wheelchair. On the bedside table was a water 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.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for three of 52 residents in the survey sample, Residents # 15 (R15), (R21) and (R96). The findings include: 1. For (R15) the facility staff failed to attempt non-pharmacological interventions prior to the administration of a prn (as needed) pain medications, roxicodone (1) and acetaminophen (2) (R15) was admitted to the facility with a diagnosis that included but was not limited to: right leg fracture. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 10/15/2022, (R15) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R15) was cognitively intact for making daily decisions. Section J0400 Pain Frequency coded (R15) as Occasionally. Under J0600. Pain Intensity it documented, A. Numeric Rating Scale (00-10). (R15) was coded a 4 (four). The physician's order for (R15) documented in part,…

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 maintain a complete dialysis program for one of 52 residents in the survey sample, Resident #36. The findings include: For Resident #36 (R36), the facility staff failed to evidence communication and coordination with the resident's dialysis provider. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/23/22, R36 was coded as being cognitively intact for making daily decisions, having scored 13 out of 15 on the BIMS (brief interview for mental status). R36 was coded as receiving dialysis services during the look back period. A review of R36's clinical record revealed the following physician order dated 5/23/22: Dialysis Thursday, Thursday, Saturday. Further review of the clinical record revealed the resident had consistently received the dialysis services as ordered in September and October 2022. A review of R36's dialysis communication book revealed only one hemodialysis communication sheet. It was dated 9/13/22. This…

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, it was determined the facility staff failed to provide performance evaluations for four of five CNA's (certified nursing assistants). The findings include: During the Sufficient and Competent Staffing facility task review on 11/2/22 at 2:00 PM there was no evidence of performance evaluations and mandatory training for four of five CNA's (certified nursing assistants) reviewed. On 11/2/22 at 9:00 AM, ASM (administrative staff member) #1, the administrator was provided a list of five CNA's with a request for evidence of performance reviews. On 11/2/22 at 10:00 AM, ASM #2, the director of nursing stated, April is when I started. I do not know if some of these performance reviews have been done. 1. CNA #4 with a date of hire of 12/15/08, evidenced no annual performance evaluation. 2. CNA #6 with a date of hire of 10/20/20, evidenced no annual performance evaluation. 3. CNA #7 with a date of hire of 12/17/20, evidenced no annual performance evaluation. 4. CNA #8 with a date of hire of 9/3/21, evidenced 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 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 failed to keep their thumbs from touching the food surfaces of the resident's plates while serving the resident's lunch in the second-floor dining room. On 10/31/2022 at approximately 12:30 p.m., an observation of the second-floor dining room was conducted. CNA (certified nursing assistant) #1 was observed with gloved hands sorting resident meal tickets on top of the ice chest, then placing the meal ticket on top of the steam table and placing their open gloved hands on top of the steam table. CNA #1 was then observed placing their thumb on the surface edge resident lunch plates when serving them to eight residents. On 10/31/2022 at approximately 1:45 p.m., an interview was conducted with CNA #1. When asked why they wore gloves when serving the resident's lunch that day CNA #1 stated that they were told to wear them. After informed of the above observation CNA #1 stated that they…

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 maintain a complete and accurate clinical record for two of 52 residents in the survey sample, Residents #6 and Resident #58. The findings include: 1. For Resident #6 (R6) the facility failed to document on the TAR (treatment administration record) the fluids provided to R6; and the CNAs (certified nursing assistants) failed to document the fluids consumed during the meals. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 10/4/2022, coded the resident as scoring a 15 out of 15, indicating the resident is not cognitively impaired for making daily decisions. R6 has a diagnosis of congestive heart failure (CHF). The physician order dated, 9/27/2022, documented, Fluid restriction - 1800 ml (milliliters) - for nursing - 300 ml 7-3 (7:00 a.m. to 3:00 p.m. shift), 300 ml for 3-11 (3:00 p.m. to 11:00 p.m.) and 120 ml for night (11:00 p.m. to 7:00 a.m.) every shift. Review of the TAR for September 2022…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, it was determined that facility staff failed to promote resident's dignity for three of 52 residents in the survey sample, Resident #26 (R26), #217(R217) and #309 (R309). The findings include: 1. For (R26), the facility staff failed to serve their meal at the same time as another resident seated at the same table. (R26) was admitted to the facility with diagnoses that included but were not limited to: quadriplegia (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/22/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section G Activities of Daily Living (ADL) Assessment coded (R26) as requiring extensive assistance of one staff member for eating. On 10/31/2022, an observation of lunch meal being served in the second floor resident dining room, revealed…

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, it was determined the facility staff failed to place calls within reach for two of 52 residents in the survey sample, Resident #79 and Resident #15. The findings include: 1. For Resident #79 (R79), the facility staff failed to ensure the call bell was within the resident's reach; it was observed on the floor. \On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 9/15/2022, the resident scored a 10 of out 15 on the BIMS (brief interview for mental status) score, indicating the resident is moderately cognitively impaired for making daily decisions. Observation was made on 10/31/2022 at approximately 12:30 p.m. of R79's room. R79 was in bed, asleep, the call bell was on the floor, out of the reach of the resident. On 11/1/2022 at 8:52 a.m. the resident was observed in his room, in his wheelchair, the call bell was on the floor, out of the reach of the resident. The comprehensive care plan dated, 6/28/2022, documented in part, Need: [R79] is at risk for fall…

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, staff interview and facility document review, it was determined that the facility staff failed to obtain or offer information of an advance directive for one of 52 residents in the survey sample, Resident #96 (R96). The finding include: For (R96), the facility staff failed to evidence an advance directive or documentation of providing information regarding an advance directive. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/05/2022, (R96) scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Review of the facility's Care Conference Minutes dated 10/25/2022 for (R96) failed to evidence of having obtain and advance directive or documentation of providing information regarding an advance directive. The POS (physician's order sheet) for (R96) dated September 2022 documented in part, Do Not Resuscitate (DNR). Order Date: 12/06/20. On 11/02/22 at approximately 3:40 p.m., an interview was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the hospital staff when three of 52 residents in the survey sample were transferred to the hospital; Residents # 95, #15 and #31. The findings include: 1. The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #95. Resident #95 was transferred to the hospital on 9/22/22. Resident #95 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: anemia, hypertension, and malnutrition. The most recent MDS (minimum data set) assessment, a 5-day Medicare assessment, with an ARD (assessment reference date) of 10/10/22, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section…

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, it was determined the facility staff failed to obtain a PASARR (preadmission screening and resident review) for one of 52 residents in the survey sample, Resident #79 (R79). The findings include: For R79, the facility staff failed to obtain a PASARR upon admission to the facility. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 9/15/2022, the resident scored a 10 of out 15 on the BIMS (brief interview for mental status) score, indicating the resident is moderately cognitively impaired for making daily decisions. R79 was admitted to the facility 10/13/2021. The review of the clinical record failed to evidence documentation of a PASARR. A request for the PASARR was made on 10/31/2022 at approximately 3:30 p.m. On 11/1/2022 at 3:27 p.m. ASM (administrative staff member) #1, the administrator, stated they did not have a PASARR for R79. An interview was conducted on 11/2/2022 at 8:44 a.m. with OSM (other staff member) #3. When asked the process for obtaining or completing…

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, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to review and revise the comprehensive care plan for two of 52 residents in the survey sample, Resident #160 and Resident #23. The findings include: 1. For Resident #160, the facility staff failed to review and revise the comprehensive care plan after four falls. On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of [DATE], the resident scored a 4 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. In Section G - Functional Status, R160 was coded as requiring extensive assistance of two or more staff members for all of her activities of daily living. In Section J - Health Conditions, the resident was coded as having had two falls with no injury during the lookback…

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, clinical record review and in the course of a complaint investigation, the facility staff failed to provide ADL (activities of daily living) care to dependent residents for one of 52 residents in the survey sample, Resident #162. The findings include: For Resident #162 (R162), the facility staff failed to provide a shower or bath on 6/23/2022, 6/27/2022, and 7/7/2022. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/29/2022, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. Section G documented R162 requiring extensive assistance of one person for personal hygiene and bathing not occurring during the 7 day assessment period. Review of the ADL (activities of daily living) documentation for R162 dated 6/1/2022-6/30/2022 documented in part, Shower/Bath. It documented the shower or bath scheduled on day shift 6/23/2022, 6/27/2022 and 6/30/2022. A shower or bath was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. For Resident #19 (R19), the facility staff failed to document a complete wound assessment of a newly identified wound and failed to follow the wound physician's orders for treatment of the wound. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 8/1/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. Section M (skin condition) of the assessment documented R19 having a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. It further documented R19 at risk of developing pressure ulcer/injuries and not having any unhealed pressure ulcer/injuries. A total body skin assessment dated [DATE] at 9:01 a.m. documented one new wound identified. The document failed to identify the location or describe the wound identified. The skin assessment was completed by RN (registered nurse) #4. The clinical record failed 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.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide care and services for an indwelling catheter for one of 52 residents in the survey sample, Residents # 217 (R217). The findings include: For (R217), the facility staff failed to keep the indwelling urinary catheter collection bag off the floor. (R217) was admitted to the facility with diagnoses that included but were not limited to: neuromuscular dysfunction of the bladder (1). The admission MDS (minimum data set) was not due at the time of the survey. The facility's Nursing Comprehensive Evaluation for (R217) dated 10/21/2022 documented in part, Neurological. Oriented To: person; Genitourinary (relating to the genital and urinary organs). Appliances: Indwelling Catheter. The physician's orders for (R217) documented in part, Routine catheter care every shift. Order date: 10/24/2022. Start Date: 10/24/2022. On 10/31/22 at 4:28 p.m., an observation of (R217's) room from the hallway revealed the indwelling urinary catheter collection bag…

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

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain complete respiratory services per professional standards for one of 52 residents in the survey sample, Resident #23. The findings include: For Resident #23 (R23), the facility staff failed to obtain a physician's order to administer oxygen. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/11/22, R23 was coded as being moderately cognitively impaired for making daily decisions, having scored seven out of 15 on the BIMS (brief interview for mental status. R23 was coded as not receiving oxygen during the look back period. On 10/31/22 at 8:42 a.m., and 11/1/22 at 8:45 a.m., R23 was observed lying in bed, with oxygen being delivered by nasal cannula at a rate of 1.5 lpm (liters per minute) by way of an oxygen concentrator. A review of R23's physician's orders revealed no evidence of an order for oxygen. A review of R23's care plan dated 10/5/22 revealed no information related to the resident's…

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

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence assessment, education and consent for the use of side rails for three of 52 residents in the survey sample, Resident #62, Resident #23, and Resident #58. The findings include: 1. For Resident #62 (R62), the facility staff failed to complete an assessment, provide education and obtain a consent for the use of side rails. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/16/2022, the resident scored a 14 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 requiring extensive assistance of one person for moving in the bed. R62 was observed on 10/31/2022 at approximately 1:00 p.m. in bed with bilateral assist rails on the bed. A second observation was made of R62 on 11/1/2022 at 11:33 a.m. in bed with bilateral assist rails.…

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 the facility staff failed to post daily nurse staffing for two of four days reviewed. The findings include: During the Sufficient and Competent Staffing facility task review started on 10/31/22 and ending on 11/3/22, a review of the daily nurse staffing evidenced the following: On 10/31/22 at approximately 11:00 AM the surveyors entered the facility. On the bulletin board in the main lobby was the staff posting with a date of 10/27/22. On 11/1/22 at 7:15 AM, the bulletin board in the main lobby had the staff posting with a date of 10/27/22. On 11/2/22 at 8:15 AM the bulletin board in the main lobby had the staff posting with a date of 11/2/22. On 11/3/22 at 8:15 AM the bulletin board in the main lobby there is staff posting with a date of 11/3/22. On 11/2/22 at 8:15 AM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked who was responsible for posting the daily staffing, ASM #2 stated, the staffing and scheduling coordinator is responsible 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, clinical record review, and facility document review, it was determined that the facility staff failed to ensure a resident was free of unnecessary medications for one of 52 residents in the survey sample, Resident #15 (R15). The findings include: For (R15), the facility staff administered a prn (as needed) pain medication Roxicodone (1) outside of the physician ordered pain level parameters. (R15) was admitted to the facility with a diagnosis that included but was not limited to: right leg fracture. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 10/15/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R15) was cognitively intact for making daily decisions. Section J0400 Pain Frequency coded (R15) as Occasionally. Under J0600. Pain Intensity it documented, A. Numeric Rating Scale (00-10). (R15) was coded a 4 (four). The physician's order for (R15) documented in part, Roxicodone Tablet 5 (five) MG (milligram). Give 1 (one) tablet by mouth…

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, clinical record review and in the course of a complaint investigation, the facility staff failed to notify the physician of critical lab results in a timely manner for one of 52 residents in the survey sample, Resident #162. The findings include: For Resident #162 (R162), the facility staff failed to act upon critical lab results reported to the facility on 7/8/2022; the facility staff did not report the critical lab results to the physician until 7/9/2022 after R162's family member inquired about them. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/29/2022, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. Section I documented R162 having an active diagnosis of anemia. Section O documented R162 receiving transfusions while not a resident of the facility and within the last 14 days. The progress notes documented in part, - 6/24/2022 12:56 (12:56 a.m.) 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.

Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for one of five CNAs (certified nursing assistants), CNA #7. The findings include: The facility staff failed to provide evidence of required certification for one of five CNAs that were employed for greater than one year, CNA #7. During the Sufficient and Competent Staffing facility task review on 11/2/22 at 2:00 PM, CNA #7's employee record contained a certification verification from the Virginia Department of Health Professions on 5/27/22. CNA #7 was hired on 12/17/20. There was no evidenced of CNA certification verification prior to 5/27/22. On 11/2/22 at 4:15 PM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked who is responsible for pulling certifications, ASM #2 stated, The staffing and scheduling coordinator and unit managers are responsible for pulling the certifications. I have not followed behind to make sure it is being done. On 11/3/22 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 2. Licensed Practical Nurse (LPN) #2 did not wear the appropriate face mask per facility protocol during medication administration on 10/31/22 at 4:10 AM. Upon entry to the facility on [DATE] at approximately 11:00 AM, ASM (administrative staff member) #1, the administrator stated, We are all wearing N95 face masks when we are in the patient units. We have four COVID positive residents and residents on observation. Observations on day shift 10/31/22, night shift 11/1/22, day/evening/night shift 11/2/22 and day/night shift on 11/3/22 evidenced staff wearing N95 masks except for one LPN on the evening shift, on 10/31/22. On 10/31/22 at 4:10 PM, LPN (licensed practical nurse) #2 was observed administering medications. The room LPN #2 was in was identified as an enhanced isolation room. LPN #2 was observed wearing a surgical mask. Upon exit from room, LPN #2 was asked what face masks they were required to wear in patient areas, LPN stated, it keeps changing. We have some Covid positive residents so I believe it is a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, facility document review, and in the course of a complaint investigation, it was determined the facility staff failed to offer and/or administer the COVID-19 vaccination to one of 9 residents reviewed for immunizations in the survey sample, Resident #162. The findings include: For Resident #162 (R162), the facility staff failed to offer the COVID-19 (1) vaccination after admission to the facility or document a contraindication for not offering the vaccination. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/29/2022, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. The comprehensive care plan for R162 documented in part, COVID-19, [R162] has the potential for developing COVID-19 infection r/t (related to) current pandemic, Has diagnosis of dementia/Alzheimer's with decreased safety awareness and…

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

Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to provide annual required training for one of five CNAs (certified nursing assistants). The findings include: The facility staff failed to provide the required mandatory training for abuse, neglect and dementia training for one of five CNAs that were employed for greater than one year, CNA #6. During the Sufficient and Competent Staffing facility task review conducted on 11/2/22 at 2:00 PM, there was no evidence of mandatory training for CNA #6. CNA #6 had a date of hire of 10/20/20, there was no evidence of dementia or abuse training. An interview was conducted on 11/2/22 at 4:00 PM with ASM #1, the administrator. When asked for the education record for CNA #6, ASM #1 stated, we do our training in the Relias system but evidently this CNA did not complete their education this year. On 11/3/22 at 3:30 PM, ASM #1, the administrator, ASM #2, the director of nursing and ASM #4, the regional clinical coordinator were made aware of the findings. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to complete and/or ensure an accurate MDS (Minimum Data Set) assessment for five of 53 residents in the survey sample; Residents #48, #1, #2, #13, and #4. 1. The facility staff failed to ensure Resident #48's quarterly MDS assessment with an ARD (assessment reference date) of 3/17/21, was accurately coded to reflect the provision of dialysis services. 2. The facility staff failed to complete a discharge MDS assessment for Resident #1's discharge to home on 1/11/21. 3. The failed to complete a discharge to the hospital MDS assessment when Resident #2 was discharged to the hospital on 2/24/21. 4. The failed to complete a discharge to the hospital MDS assessment when Resident #13 was discharged to the hospital on 2/23/21. 5. The facility staff failed to complete an accurate MDS assessment, in Section H bowel and bladder on Resident #4's 3/18/21 discharge assessment. Resident #4 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to obtain informed consent for the use of positioning / assist bars prior to use for six of 53 residents in the survey sample; Residents #94, #78, #106, #52, #99, and #15. The findings include: A review of the facility policy, Side rail / Bed / Mattress Spacing documented, Facilities will ensure that all beds are free from areas of possible entrapment which may pose a risk of hazards or serious injury. Procedure: 1. A Physical Device Evaluation will be completed if the facility determines a side rail is needed to evaluate for the risk of entrapment. 2. If a side rail is implemented the facility must obtain informed consent from the guest/resident, or if applicable, the resident representative for the use of side rails 1. Resident #94 was admitted to the facility on [DATE] with the diagnoses of but not limited to dementia, psychosis, insomnia, high blood…

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 interviews it was determined that the facility failed to maintain a complete and accurate clinical record for one of 53 residents in the current resident sample, Resident #3. The facility staff failed to maintain a complete and accurate clinical record documenting treatments completed for Resident #3. The findings include: Resident #3 was admitted to the facility with diagnoses that included but were not limited to pressure ulcer (1), adult failure to thrive (2) and intellectual disabilities (3). Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 5/6/21 coded Resident #3 as scoring a 0 (zero) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 0- being severely impaired for making daily decisions. Section G coded Resident #3 as requiring extensive assistance of one person for bed mobility, eating and personal hygiene and two or more staff for transfers and toilet use. Section M coded Resident #3 having two stage 4 pressure ulcers,…

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 5. The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #81 to identify areas of possible entrapment. Resident #81 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes mellitus (the inability of insulin to function normally in the body) (1), peripheral vascular disease (abnormal condition including atherosclerosis affecting blood vessels outside of the heart) (2) and atrial fibrillation (rapid and random contractions of the atria of the heart) (3). Resident #81's most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 4/24/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status, coded the resident as requiring extensive assistance in bed mobility, transfers, locomotion, dressing, bathing, toileting and personal hygiene; supervision…

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 that the facility staff failed to maintain a resident's dignity for two of 53 residents in the survey sample, Resident #32 and Resident #3. The facility staff were observed feeding Resident #32 and Resident #3 while standing beside the residents. The findings include: Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including history of a stroke, a hip fracture, and COPD (chronic obstructive pulmonary disease) (1). The most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/23/21, coded Resident #32 as severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the assistance of one staff member for eating. On 6/1/21 at 1:90 p.m., Resident #32 was observed sitting up in her bed. CNA (certified nursing assistant) #1 was standing up…

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 of a resident's documented significant weight gain for one of 53 residents in the survey sample, Resident #32. The facility staff failed to notify the physician of Resident #32's documented significant weight gain, as documented in the May 2021 clinical record. The findings include: Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including history of a stroke, a hip fracture, and COPD (chronic obstructive pulmonary disease) (1). The most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/23/21, coded Resident #32 as severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). She was coded as having no significant weight gain or loss prior to her admission to the facility. A review of Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to maintain a clean, comfortable, home like environment for one of 53 residents in the survey sample, Resident #84. The facility staff failed to clean up a spill, which caused Resident #84's floor to be sticky, for more than 24 hours. The findings include: Resident #84 was admitted to the facility on [DATE] with diagnoses including a subdural hemorrhage (1), history of a stroke, and paranoid personality disorder (2). The most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/30/21, coded Resident #84 as severely cognitively impaired for making daily decisions. On 6/1/21 at 12:16 p.m., Resident #84 was observed lying in bed. On the floor beside her bed, several large patches of dried liquid were observed. The floor in these areas was sticky. On 6/1/21 at 3:42 p.m., Resident #84 was observed sitting in the wheelchair beside her bed. The spots on the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for three of 53 residents in the survey sample, Residents #32, #49, and #61. 1a The facility staff failed to implement Resident #32's comprehensive care plan to place fall mats on the floor beside the bed when Resident #32 is in bed. b. The facility staff also failed to implement Resident #32's care plan to notify the physician of a documented significant weight gain 2. The facility staff failed to develop a comprehensive care plan to address Resident #49's left leg prostheses. 3. The facility staff failed to develop a comprehensive care plan to address activities for Resident #61. The findings include: 1. The facility staff failed to implement Resident #32's care plan for safety from falls. The staff did not place fall mats beside Resident #32's bed while she was occupying the bed. The facility…

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 the facility staff failed to review and revise the care plan for one of 53 residents in the survey sample, Resident # 61. The findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (1), atrial fibrillation(a condition characterized by rapid and random contraction of the atria of the heart causing irregular beats of the ventricles and resulting in decreased heart output and frequently clot formation in the atria)(2), and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.) (3). The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 4/15/2021, coded the resident as scoring a 4…

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, it was determined that the facility staff failed to follow professional standards of practice for a Registered Nurse's assessment and declaration of the death of a resident to be documented in the clinical record by the Registered Nurse, for one of 53 residents in the survey sample, Resident #113. The findings include: Resident #113 was admitted to the facility on [DATE] and expired at the facility on [DATE]. The resident had the diagnoses of but not limited to left femur fracture, atrial fibrillation, morbid obesity, COVID-19, acute respiratory failure, anxiety, psychosis, insomnia, high blood pressure and dementia. The admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] coded the resident as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing and extensive assistance for all other areas of activities of daily living. A…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and review of facility documentation the facility staff failed to implement preventative measures to ensure a safe environment for one of 53 residents in the survey sample, Resident #32. The facility staff failed to place a fall mat beside Resident #32's bed to prevent falls/injury per the comprehensive care plan. Multiple observations revealed Resident #32 in bed without a fall mat on the floor. The findings include: Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including history of a stroke, a hip fracture, and COPD (chronic obstructive pulmonary disease) (1). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/23/21, Resident #32 was coded as being severely cognitively impaired for making daily decisions, having scored five out of 15 on the BIMS (brief interview for mental status). She was coded as having had one fall with major injury. On the…

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

Based on observation, resident interview, staff interview, and facility document review it was determined that the facility staff failed to monitor and implement interventions to prevent a significant weight loss for one 53 residents in the survey sample, Resident #24. The facility staff failed to prevent a significant weight loss for Resident #24 between 11/16/2020 and 2/9/2021. On 11/16/2020, Resident #24 weighed 207.9 lbs (pounds) and on 2/9/2021, Resident #24 weighed 177.4 for a 30.5 lb (pound) (14.67 %) weight loss. The findings include: Resident #24 was admitted to the facility with diagnoses that included but were not limited to heart failure (1), adult failure to thrive (2), and diabetes (3). Resident #24's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/15/2021, coded Resident #24 as scoring a 4 (four) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 4- being severely impaired for making daily decisions. Section G coded Resident #24 requiring extensive assistance of one person for eating. Section…

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.