Shenandoah Valley Health And Rehab

Based on staff interview and facility document review, the facility staff failed to ensure the proper timeframe was in place to rescind a binding arbitration agreement for residents in the facility. Findings were: During the entrance conference on 02/21/2023 at approximately 1:00 p.m., the administrator was asked if residents or his/her representatives were asked to enter into a binding arbitration agreement with the facility. She responded, Yes. A copy of the facility arbitration agreement was requested. On 02/23/2023 at approximately 9:45 a.m., the VOLUNTARY ARBITRATION AGREEMENT PROGRAM GUIDE was reviewed and contained the following process listed under ARBITRATION PROCEDURES: If you sign the Agreement and later change your mind, you will have ten (10) business days from the date of execution of the Agreement to completely cancel and void the Agreement. Further review of the VOLUNTARY ARBITRATION AGREEMENT included the following: Right to Change Your Mind: The resident will receive from the Facility a copy of this agreement upon it being fully executed. This Agreement may be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review the facility staff failed to follow professional standards of practice during medication administration for one of 19 residents in the survey sample: Resident # 33. Findings include: Resident # 33 was admitted to the facility 2/20/20 with diagnoses to include, but were not limited to: end stage renal disease, heart disease, high blood pressure, and insomnia. The most recent MDS (minimum set) was quarterly assessment dated [DATE]. Resident # 33 was assessed as cognitively intact with a total summary score of 15/15. On 2/21/23 beginning at approximately 3:00 p.m. during review of the clinical record, a nurses note dated 2/15/23 at 3:48 p.m. documented Resident was given the medication of another resident by mistake. Medication was Bethanechol (helps with urination)10 mg, Xanax (anti-anxiety) 0.5 mg, Cipro (antibiotic) 500 mg, Iron 325 mg, Fluvoxamine (antidepressant) 50 mg, Gabapentin (anticonvulsant) 200 mg,…

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

Based on a medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5 percent. The facility had two medication errors out of 28 medication opportunities, which resulted in a medication error rate of 7.14 percent. Findings include: On 02/22/23 at 8:29 AM, a medication pass and pour observation was completed with Licensed Practical Nurse (LPN) #1. LPN #1 prepared medications for Resident #35, which included Vitamin C 500 milligrams (mg) (one tablet), Ferrous Sulfate 325 /65 mg (one tablet), Losartan Potassium 100 mg (one tablet), Miralax 17 grams (mixed with water) and Pravastatin Sodium Tablet 40 MG (one tablet). The resident had a total of 4 tablets and the Miralax mixture. The LPN administered the medication to Resident #35. At approximately 9:45 AM, a medication reconciliation was completed for Resident #35. The resident's physician's orders revealed the resident had an order for Protonix 40 mg once daily. The Protonix 40 mg was ordered on 02/21/23 and 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 resident interview, staff interview, clinical record review, and facility document review the facility staff failed to ensure one of 19 residents in the survey sample was free from a significant medication error: Resident # 33. Findings include: Resident # 33 was admitted to the facility 2/20/20 with diagnoses to include, but were not limited to: end stage renal disease, heart disease, high blood pressure, and insomnia. The most recent MDS (minimum set) was quarterly assessment dated [DATE]. Resident # 33 was assessed as cognitively intact with a total summary score of 15/15. On 2/21/23 beginning at approximately 3:00 p.m. during review of the clinical record, a nurses note dated 2/15/23 at 3:48 p.m. documented Resident was given the medication of another resident by mistake. Medication was Bethanechol (helps with urination)10 mg, Xanax (anti-anxiety) 0.5 mg, Cipro (antibiotic) 500 mg, Iron 325 mg, Fluvoxamine (antidepressant) 50 mg, Gabapentin (anticonvulsant) 200 mg, Lisinopril (for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 19 residents in the survey sample: Resident # 33. Findings include: Resident # 33 was admitted to the facility 2/20/20 with diagnoses to include, but were not limited to, end stage renal disease, heart disease, high blood pressure, and insomnia. The most recent MDS (minimum set) was quarterly assessment dated [DATE]. Resident # 33 was assessed as cognitively intact with a total summary score of 15/15. On 2/21/23 beginning at approximately 3:00 p.m. during review of the clinical record, a nurses note dated 2/15/23 at 3:48 p.m. documented Resident was given the medication of another resident by mistake. Medication was Bethanechol (helps with urination)10 mg, Xanax (anti-anxiety) 0.5 mg, Cipro (antibiotic) 500 mg, Iron 325 mg, Fluvoxamine (antidepressant) 50 mg, Gabapentin (anticonvulsant) 200 mg, Lisinopril (for high blood pressure), Metformin (lowers…

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

Based on a medication pass and pour observation, staff interview, and facility document review, the facility staff failed to ensure infection control practices during the administration of medications. Findings include: On 02/22/23 at 8:29 AM, a medication pass and pour observation was conducted with LPN (Licensed Practical Nurse) #1. The LPN did not wash or sanitize her hands prior to preparing medications for Resident #67. The LPN prepared and administered the medications to Resident #67, left the resident's room and immediately began to prepare Resident #35. The LPN did not wash and/or sanitize her hands before proceeding to the next resident. LPN #1 prepared Resident #35's medications and administered the medications to the resident. LPN #1 left the resident's room, did not wash and/or sanitizer her hands and immediately began to prepare medications for Resident #9. LPN #1 prepared and administered medications to Resident #9, exited the room and then retrieved the hand sanitizer on the medication cart to cleanse her hands. At this time (8:53 AM), LPN #1 was made aware that she…

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, facility document review and staff interview, the facility staff failed to ensure a facility wide assessment was completed and documented to include infection control practices related to COVID-19 for day to day operations and during emergencies. The facility assessment failed to include care required by the resident population considering infection control practices and/or for infection control related to COVID-19 residents, that were present within that population. The facility assessment also failed to include input from the administrator, the DON (director of nursing) and the medical director. Findings include: During the survey conducted 05/25/21 through 05//27/21, it was identified that the facility had an active outbreak of COVID-19. The facility had six active cases of COVID 19. The facility had utilized 6 rooms [hot unit] for active COVID residents, and 4 rooms for observation [warm unit], which was used for new admissions, readmissions, exposure residents or residents with suspected COVID 19. On 05/26/21 at approximately 10:15 AM, during a review 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 observation, staff interview and clinical record review, the facility staff failed to provide a complete and accurate record for the documentation of dietary orders for 2 of 22 in the survey sample, Resident #365 and Resident #366; and failed to ensure a complete and accurate record for the documentation of immunization records for 3 of 22 in the survey sample, Resident #165, Resident #60, and Resident #366. The findings include: 1. Resident #365 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, chronic kidney disease - stage 3, hyperkalemia, hypertension, acidosis, and heart failure. The nursing admission assessment dated [DATE] documented Resident #365 as independent for daily decision-making. On 05/25/2021 at 12:35 p.m., Resident #365 was observed in her room eating lunch. The lunch meal ticket documented the diet order as Regular - Dysphasia Advanced. Resident #365 was asked if she knew what type of diet she was supposed to have. Resident #365 stated, all I know is…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to develop policies and procedures for infection control practices for droplet precautions, and failed to follow infection control practices during dressing changes for one of 22 residents in the survey sample (Resident #50). Findings include: On 05/25/21, upon entrance, the facility was found in an active outbreak of COVID-19. The facility reported six COVID positive residents who were in isolation on the hot unit, and reported six residents in isolation on the warm unit for precautionary measures. On 05/25/21 at approximately 10:45 AM, the DON (director of nursing) explained where the hot and warm units were. A tour of the hot unit was conducted. An industrial strip curtain was hanging as a barrier separating the hot unit from the cold area. There was no signage on the curtain or in that area to inform of what unit this was or what protocol to follow. Once through the hanging curtain, a holding…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide an appropriate adaptive light switch and ensure accessibility to a call bell for one of 22 residents in the survey sample. Resident #50, with limited range of motion and mobility was observed with his call bell out of reach. The cord for Resident #50's over-bed light was too short for resident use and was modified with a plastic bag attached to the end of the cord. The findings include: Resident #50 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #50 included multiple sclerosis, chronic pressure ulcers, diabetes, encephalopathy, reflex neuropathic bladder, insomnia, dementia and abnormal posture. The minimum data set (MDS) dated [DATE] assessed Resident #50 with moderately impaired cognitive skills and as requiring extensive assistance of two people for bed mobility, total assistance of two people for transfers and limited functional range 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 clinical record review, family interview, and staff interview, the facility staff failed to ensure an advance directive was followed for one of 22 residents (Resident #60). Resident #60 had an advance directive prior to entry into the facility that appointed his wife as DPOA (durable power of attorney) to make medical decisions for the resident [in the event the resident could not]. The facility failed notify the resident's wife regarding code status of the resident, upon the resident's admission to the facility. The facility had Resident #60 sign his own DNR (do not resuscitate) after the facility had identified and assessed the resident with severe cognitive impairment. Finding include: Resident #60 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to: CAD (coronary artery disease), heart failure with pace maker placement, high blood pressure and DM (diabetes mellitus) with severe vision loss, dementia, and encephalopathy. The most recent full MDS (minimum data set) was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 22 residents was free from neglect. Facility staff failed to promptly assess, notify the provider, and obtain treatment orders for Resident #50 regarding a newly identified pressure ulcer. The findings include: Resident #50 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #50 included multiple sclerosis, chronic pressure ulcers, diabetes, encephalopathy, reflex neuropathic bladder, insomnia, dementia and abnormal posture. The minimum data set (MDS) dated [DATE] assessed Resident #50 with moderately impaired cognitive skills and as requiring extensive assistance of two people for bed mobility, total assistance of two people for transfers and limited functional range of motion in both upper and lower extremities. Resident #50's clinical record documented the resident had a history of pressure ulcers and was currently treated for pressure…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to develop a CCP (comprehensive care plan) for a central line and transmission based precautions secondary to MRSA, for one of 22 residents in the survey sample (Resident #217) . Findings included: Resident #217 was admitted to the facility on [DATE]. Diagnoses for Resident #217 included: MRSA (methacillin resistant staphylococcus aureus), acute respiratory failure, pneumonia due to corona virus, and kidney transplant. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 5/14/21. Resident #217 was assessed with a cognitive score of 11 indicating moderately cognitively intact. On 5/27/21 Resident #217's clinical record was reviewed. According to physician's orders, Resident #217 had a active case of MRSA and was receiving Vancomycin (antibiotic) via a PICC line (Peripherally Inserted Central Catheter). Resident #217's care plan was then reviewed and did not include a care plan for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to revise the comprehensive care plan for one of 22 residents in the survey sample. Resident #50's plan of care was not revised to include use of a cushion, wedge, and pillows for positioning and prevention of skin impairments. The findings include: Resident #50 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #50 included multiple sclerosis, chronic pressure ulcers, diabetes, encephalopathy, reflex neuropathic bladder, insomnia, dementia and abnormal posture. The minimum data set (MDS) dated [DATE] assessed Resident #50 with moderately impaired cognitive skills and as requiring extensive assistance of two people for bed mobility, total assistance of two people for transfers and limited functional range of motion in both upper and lower extremities. Resident #50's clinical record documented the resident was currently treated for pressure ulcers that included two stage 4 pressure…

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 and staff interview, the facility staff failed to follow physician's orders for one of 22 residents in the survey sample (Resident #60) for weekly weights. Finding include: Resident #60 was admitted to the facility on [DATE]. Diagnoses for Resident #60 included, but were not limited to: CAD (coronary artery disease), heart failure with pace maker placement, high blood pressure and DM (diabetes mellitus) with severe vision loss, dementia, and encephalopathy. The most recent full MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 05/04/21. The resident was assessed on this MDS with a weight of 202.0 lbs [pounds]. The resident was assessed with a cognitive score of 3, indicating the resident had severe impairment in daily decision making skills, as well as inattention and disorganized thinking. The clinical record was reviewed on 05/26/21 9:13 AMz. Physician's orders included, .Weekly weights X [times] 4 every day shift every Mon for 4 weeks…

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

Based on observation, staff interview and clinical record review, the facility staff failed to ensure a medication was available for administration to one of four residents in a medication pass observation. The supplement PreserVision AREDS was not available for administration to Resident #33. The findings include: A medication pass observation was conducted on 5/26/21 at 8:00 a.m. with licensed practical nurse (LPN #2) administering medications to Resident #33. During this observation, LPN #2 administered a Thera-M multivitamin tablet instead of physician ordered PreserVision AREDS. Resident #33's clinical record documented a physician's order dated 1/5/21 for PreserVision AREDS once per day as a supplement. On 5/26/21 at 9:37 a.m., the consultant pharmacist (other staff #6) was interviewed about the administration of a multivitamin instead of PreserVision AREDS to Resident #33. The pharmacist stated the PreserVision AREDS had higher concentrations of vitamin C, vitamin A, vitamin E, zinc and copper for eye health and should be provided as ordered instead of the standard…

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

Based on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5%. A medication pass observation revealed two errors out of 38 opportunities resulting in a 5.26% error rate. Resident #33 was administered a multivitamin instead of physician ordered PreserVision AREDS and was administered Senna instead of physician ordered Senna-Docusate Sodium. The findings include: A medication pass observation was conducted on 5/26/21 at 8:00 a.m. with licensed practical nurse (LPN #2) administering medications to Resident #33. During this observation, LPN #2 administered a Thera-M multivitamin tablet and one tablet of Senna 8.6 mg (milligrams). Resident #33's clinical record documented a physician's order dated 1/5/21 for PreserVision AREDS once per day and an order dated 1/4/21 for Senna with Docusate Sodium 8.6-50 mg twice daily for constipation. On 5/26/21 at 9:37 a.m., the consultant pharmacist (other staff #6) was interviewed about the administration of a multivitamin instead of PreserVision AREDS to Resident #33. 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 resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to implement food preferences for two of 22 residents in the survey sample. Resident # 365 and Resident #366 were not interviewed to discuss food and/or dining preferences. The findings include: 1. Resident #365 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, chronic kidney disease - stage 3, hyperkalemia, hypertension, acidosis, and heart failure. The nursing admission assessment dated [DATE] documented Resident #365 as independent for daily decision-making. On 05/25/2021 at 12:35 p.m., Resident #365 was observed in her room eating lunch. Resident #365 was interviewed regarding her food preferences and dining experiences. Resident #365 stated, I have been to several facilities and the food here is to be desired. Look at my tray, I'm getting some kind of advanced chopped food instead of regular food that I want, and there are no condiments on here…

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 ensure an interdisciplinary team was in attendance at care plan meetings for two of 21 residents, Resident #57 and Resident #13. The facility also failed to invite one of 21 residents, Resident #13 to his care plan meeting. 1. Resident #53's, (a resident with significant weight loss) care plan was not reviewed by an interdisciplinary team from 06/12/2018 through 02/19/2019. 2. For two consecutive quarters, Resident #13's care plan was not reviewed/revised by an interdisciplinary team. In addition, Resident #13 was not invited to participate in his quarterly care plan meetings. Findings were: 1. Resident #53 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Major depressive disorder, anxiety, hypertension, hypothyroidism, dementia with behavioral disturbances, atherosclerotic heart disease, atrioventricular block (with subsequent pacemaker insertion) and cancer (per…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to maintained acceptable parameters of nutritional status for one of 21 residents in the survey sample, Resident #53. Resident #53 had a significant weight loss of 24.49 % in six months. Facility staff were not aware of what foods on Resident #53's tray were fortified at meal times, and minimal assistance was offered during meal time observations. Findings were: Resident #53 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Major depressive disorder, anxiety, hypertension, hypothyroidism, dementia with behavioral disturbances, atherosclerotic heart disease, atrioventricular block (with subsequent pacemaker insertion) and cancer (per facility staff report). A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 02/13/2019, assessed Resident #53 as severely impaired in cognitive status with a summary score of 00. Under Section G Functional Status, Resident #53…

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 the facility staff failed to ensure medications and biologicals were properly stored and labeled on one of 2 units: Unit 2. One of 2 opened vials of PPD (tuberculin skin test) solution was expired and available for administration. The refrigerator temperatures for February 2019 and [DATE] were out of range with no adjustment made. Findings include: On [DATE] at 8:00 a.m. an inspection of the medication room and refrigerator was conducted with LPN (licensed practical nurse) # 1. One of 2 open PPD vials was opened and identified as expired. The vial had an open date of [DATE]. LPN # 1 was asked when it should be discarded. She stated I think 30 days after opening; let me check. LPN # 1 looked at a laminated sheet on a cork board and stated Yes, after 30 days. She then removed the vial of PPD from the refrigerator. A copy of the sheet referencing the storage instructions for the PPD was requested. The sheet, titled Special Storage Instructions from…

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

Based on observation and staff interview, the facility failed to ensure a homelike environment. In Resident #54's room, the drywall around the ceiling was in ill repair and the commode was not functioning properly. The findings include: On 3/12/19 at 11 a.m., during the initial tour, Resident #54 stated there had been a problem with the commode and a crack in the ceiling since she had been admitted . The resident stated the commode constantly runs after you flush it, we try jiggling the handle and sometimes it cuts off and sometimes it does not. Resident #54 opened the bathroom door and the commode was observed constantly running for about 2 minutes. Resident #54 continued and pointed to the ceiling and stated look at that crack in the ceiling. A crack was observed running around the right edge of the ceiling near bed A for approximately 12 feet heading towards overtop of the closet area. Resident #54 said she was not sure of the repair status but staff were aware of the problem. Resident #54 stated she was concerned and did not want the ceiling to fall in on her and her roommate.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive plan of care for one of 21 residents in the survey sample. Resident #13 did not have a comprehensive care plan developed regarding required supervision related to inappropriate behaviors. The findings include: Resident #13 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #13 included atrial fibrillation, diabetes, high blood pressure, COPD (chronic obstructive pulmonary disease), macular degeneration and depression. The minimum data set (MDS) dated [DATE] assessed Resident #13 as cognitively intact. Resident #13's clinical record documented on 1/11/19 that a staff member witnessed the resident with his hand down a female resident's shirt while in the dining room. A facility reported incident form sent to the State Agency dated 1/16/19 documented the resident was evaluated by psychiatry and had medications reviewed/adjusted in response to the incident. 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, resident interview, staff interview and clinical record review, the facility staff failed to anchor the tubing for a Foley urinary catheter for one of 21 residents in the survey sample. Resident #184 did not have the Foley catheter tubing anchored to her thigh as required in her plan of care. The findings include: Resident #184 was admitted to the facility on [DATE] with diagnoses that included femur fracture, urinary retention, lung cancer, pleural effusion, diabetes and COPD (chronic obstructive pulmonary disease). The admission nursing assessment documented Resident #184 was alert and oriented with some confusion. On 3/12/19 at 4:11 p.m., Resident #184 was observed in bed. The resident's Foley catheter tubing was visible and not anchored to the resident's thigh. Resident #184 was interviewed at this time about the tubing. Resident #184 stated the tubing had not been attached to her thigh since her admission. Resident #184's clinical record documented a physician's order dated 3/11/19 for…

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