Albemarle Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of quality during medication administration for two of eight residents in the survey sample (Residents #5 and #6). The findings include: On 2/22/25, oral medications were prepared ahead of the scheduled administration time and left unattended/unsecured at the bedside for two residents (Residents #5 and #6). The nurse failed to observe R5 take the prepared medications. Resident #5 (R5) was admitted to the facility with diagnoses that included diabetes, asthma, atrial fibrillation, anorexia, depression, neuropathy, chronic kidney disease, anxiety and insomnia. The minimum data set (MDS) dated [DATE] assessed R5 as cognitively intact. Resident #6 (R6) was admitted to the facility with diagnoses that included spinal stenosis, osteoporosis, peripheral vascular disease, gastroesophageal reflux disease, insomnia, depression, anxiety and hypertension. The MDS dated [DATE] assessed R6…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to follow physician orders for medication administration for one of eight residents in the survey sample (Resident #4). The findings include: Resident #4 (R4) was admitted to the facility with diagnoses that included osteomyelitis, MRSA (methicillin resistant staphylococcus aureus), end stage renal disease, protein-calorie malnutrition, anemia, hypertension and diabetes. The minimum data set (MDS dated [DATE] assessed R4 as cognitively intact. R4's closed clinical record documented a physician's order dated 1/30/25 for Zosyn (piperacillin - tazobactam) intravenous (IV) solution reconstituted 4.5 (4-0.5) grams with instructions to give 4.5 grams intravenously every 12 hours until 3/5/25 for treatment of acute osteomyelitis. R4's medication administration record (MAR) for February 2025 documented Zosyn was scheduled for administration at 6:00 a.m. and 6:00 p.m. each day. The MAR documented Zosyn was not…

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 ensure medications remained secured in locked compartments and/or carts for two of eight residents in the survey sample (Residents #5 and #6). The findings include: Resident #5 (R5) was admitted to the facility with diagnoses that included diabetes, asthma, atrial fibrillation, anorexia, depression, neuropathy, chronic kidney disease, anxiety and insomnia. The minimum data set (MDS) dated [DATE] assessed R5 as cognitively intact. Resident #6 (R6) was admitted to the facility with diagnoses that included spinal stenosis, osteoporosis, peripheral vascular disease, gastroesophageal reflux disease, insomnia, depression, anxiety and hypertension. The MDS dated [DATE] assessed R6 as cognitively intact. 1. The medication Trelegy Ellipta inhaler was observed stored unsecured on Resident #5's bedside table. On 6/10/25 at 10:45 a.m., R5 was observed in her room with a Trelegy Ellipta…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to include insulin administration in the baseline care plan for one of three residents in the survey sample (Resident #11). The findings include: Resident #11's baseline care plan included no goals/interventions regarding insulin administration with use of an insulin pump. Resident #11 (R11) was admitted to the facility with diagnoses that included Parkinson's, diabetes, asthma, hypertension, irritable bowel syndrome, self-imposed factitious disorder, chronic atrial fibrillation, and hyperlipidemia. An admission assessment date 8/1/24 listed R11 as cognitively intact and oriented to person, place, time and situation. R11's clinical record documented the resident was admitted to the facility with use of an insulin pump for insulin administration related to diabetes. R11's hospital Discharge summary dated [DATE] documented the resident had his own insulin pump and had demonstrated sufficient ability 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 staff interview and clinical record review the facility staff failed to review and revise a comprehensive care plan for one resident, Resident #13 (R13) out of three residents in the survey. The findings included: The facility staff failed to review and revise R13's care plan with weight bearing status. On 2/4/25 at 9:45 a.m. an interview was conducted with the therapy manager. The therapy manager stated that R13 participated in physical therapy. He stated that R13 was non weight bearing to right leg. On 2/4/25 at 9:57 a.m. an interview was conducted with a certified nursing assistant, CNA#3 (CNA3). CNA3 said, if resident is non weight bearing therapy will evaluate and let us know. We don't know weight bearing status until therapy evaluates but sometimes the nurse reports it to us. On 2/4/25 at 10:00 a.m. an interview was conducted with a licensed practical nurse, LPN#3 (LPN3). LPN3 stated that when she receives report about the patient's weight bearing status that she would give report to the aide. LPN3 stated she would expect weight bearing status to be on 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 staff interview and facility document review, the facility staff failed to provide sufficient dietary staff to provide timely meal delivery on four of four units. The findings include: There was an insufficient number of dietary staff working on 6/9/24 to provide preparation and service of breakfast for residents within the facility. Review of the dietary department as-worked schedule for 6/9/24 revealed that no dietary employees worked in the main kitchen, other than the dietary manager. A hand-written employee schedule documented one cook, and five dietary aides were scheduled to work on 6/9/24 from 6:00 a.m. until 2:00 p.m. This schedule documented the cook and the five dietary aides either called out, went home, or were a no-show on 6/9/24. On 11/12/24 at 3:10 p.m., the dietary manager (other staff #8) was interviewed about kitchen staff on 6/9/24. The dietary manager stated that she was newly hired on 6/4/24. The dietary manager stated there were conflicts with the cook working at that time and all the kitchen staff scheduled for the day shift on 6/9/24 did not show…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and facility document review, the facility staff failed to provide timely breakfast service on four of four units. The findings include: There was no cooked breakfast provided to residents in the facility on the morning of 6/9/24. Posted breakfast times were 8:00 a.m. on the 200 and 300 units and at 8:30 a.m. on the 100 and 400 units. Posted mealtimes documented dinner was served daily at 5:00 p.m. (200, 300 units) and 5:30 p.m. (100, 400 units). Review of the dietary department as-worked schedule for 6/9/24 revealed no dietary employees worked in the main kitchen. A hand-written employee schedule documented one cook and five dietary aides were scheduled to work on 6/9/24, from 6:00 a.m. until 2:00 p.m. This schedule documented the cook, and the five dietary aides either called out, went home, or were a no show on 6/9/24. On 11/12/24 at 3:10 p.m., the dietary manager (other staff #8) was interviewed about kitchen staff on 6/9/24. The dietary manager stated she was newly hired on 6/4/24.…

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 ensure a therapeutic diet and provide foods correctly per meal ticket for four of five residents in the survey sample (Residents #1 through #4). The findings include: 1. Resident #2 (R2) was not provided a diabetic diet for lunch and was not provided foods per meal ticket for breakfast. Resident #3 (R3) was not provided a diabetic diet for lunch. Resident #4 (R4) was not provided foods per meal ticket for breakfast. The R2's clinical record indicated that R2 had diagnoses that included Diabetes, anemia, and anorexia. MDS (minimal Data Set) dated 11/5/24 indicated R2 was severely cognitively impaired. The R3's clinical record indicated that R3 had diagnoses that included: Diabetes, gout, and obesity. MDS (minimal Data Set) dated 9/30/24 indicated R3 was severely cognitively impaired. The R4's clinical record indicated that R4 had diagnoses that included: neuropathy and dysphasia. MDS (minimal Data…

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 store, prepare, and serve food in a sanitary manner from the main kitchen and on two of four kitchenettes (200-unit, 300-unit). The findings include: In the main kitchen, multiple food items were stored beyond use-by dates, with no prep dates and/or opened dates and/or were unsealed in the freezer. Bulk condiment storage containers, flour/sugar bins and the manual can opener were dirty. An employee was observed in the kitchen during meal preparation without a hair restraint. Employee food items were stored in the walk-in refrigerator. On the 200 and 300 units, foods were held on the kitchenette steam tables below recommended safe temperatures and served to residents without reheating. a) The main kitchen was inspected on 11/12/24 at 10:50 a.m., accompanied by the dietary manager (other staff #8). Observed stored in the walk-in refrigerator was a plastic bag containing chopped chicken, cheese, and tortillas. 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, and clinical record review, the facility staff failed to accommodate a preference for showers twice each week for one of five residents in the survey sample (Resident #1). The findings include: Resident #1 (R1) was admitted to the facility with diagnoses that included congestive heart failure, hypertension, arthritis, and lymphedema. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact and as requiring supervision and/or touch assistance with bathing. On 11/12/24 at 1:10 p.m., R1 was interviewed about his shower schedule and preference for bathing. R1 stated he wanted two showers each week. R1 stated at times he did not receive twice weekly showers according to his preference. R1's clinical record documented the resident did not receive showers twice per week during February 2024 and March 2024. R1's bath/shower records documented the resident had no showers during the week of 2/11/24 through 2/17/24; one shower (on 2/22/24) during the week of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of five residents in the survey sample (Resident #1). The findings include: Nursing staff failed to document treatments provided to Resident #1 at the time the care was provided. Resident #1 (R1) was admitted to the facility with diagnoses that included congestive heart failure, hypertension, arthritis, and lymphedema. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented physician orders for the following treatments listed with the date ordered: 8/14/24 - Zeasorb-AF external powder 2%, apply to abdominal folds, gluteal cleft and behind left knee topically every day and evening shift for treatment of yeast. 8/24/24 - Apply zinc barrier cream twice per day to intergluteal cleft discoloration and leave open to air. 8/24/24 - Change bilateral Circaid wraps every day, inspect skin, wash/dry legs, apply lotion…

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 follow physician orders for one of five residents in the survey sample (Resident #1). The findings include: Resident #1 did not have topical powder and zinc barrier cream applied or leg wraps changed as ordered by the physician. Resident #1 (R1) was admitted to the facility with diagnoses that included congestive heart failure, hypertension, arthritis, and lymphedema. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented orders for the following treatments: 8/14/24 - Zeasorb-AF external powder 2%, apply to abdominal folds, gluteal cleft and behind left knee topically every day and evening shift for treatment of yeast. 8/24/24 - Apply zinc barrier cream twice per day to intergluteal cleft discoloration and leave open to air. 8/24/24 - Change bilateral Circaid wraps every day, inspect skin, wash/dry legs, apply lotion with new pair of liners each day shift. R1's clinical record…

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

Based on resident interview, observation, staff interview, and facility document review, the facility staff failed to provide food at an appetizing temperature on one of four units (200-unit). The findings include: Review of monthly resident council minutes from May 2024 through October 2024 revealed ongoing complaints from residents about meals served with foods not at adequate temperature. There was no documented follow up on the council minutes regarding interventions or actions taken in response to the food complaints. On 11/12/24 at 1:10 p.m., the resident council president (Resident #1) was interviewed about any resident concerns with food/meals. The council president stated that residents reported and complained about cold food all the time. The council president stated cold food had been brought up in most of the council meetings during the last several months. On 11/12/24 at 12:20 p.m., the meal service from the 200-unit kitchenette was observed. The dietary aide (other staff #6) checked food temperatures, with multiple food items measured below the required 135 degrees…

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 provide foods accommodating resident preferences for one of five residents in the survey sample (Resident #1). The findings include: Resident #1's food preferences were not honored. According to the clinical record review, Resident #1 (R1) was admitted to the facility with diagnoses that included congestive heart failure, hypertension, arthritis, and lymphedema. Also documented was a minimum data set (MDS) dated [DATE], which assessed R1 as cognitively intact. On 11/12/24 at 1:10 p.m., R1 was observed with lunch. The foods served to R1 were compared to the meal ticket provided with the meal. R1 was served two baked chicken breasts, mashed potatoes, mixed vegetables, a roll, chocolate cupcake and yogurt. R1's meal ticket included the baked chicken, yogurt, and vegetables but did not list the mashed potatoes, roll, or cupcake. The ticket listed a tossed salad with dressing, which was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide feeding assistance for 2 of 5 resident in the survey sample, Resident #4 (R4) and Resident #5 (R5). The findings included: 1. The facility staff failed to assist R4 with dentures and ensure they were put in place prior to feeding the resident. R4 was admitted to the facility on [DATE]. Diagnoses for R4 included but are not limited to dysphagia, oral phase. R4's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 6/22/24 coded R4 with moderate cognitive impairment. R4 was coded in section G with needing extensive feeding assistance of one person. On 7/26/24 at 8:15 a.m. an observation was made of the breakfast meal. R4' s breakfast meal was taken in her room and left within in her reach without facility staff remaining in the resident's room. Facility staff did not assist R4 with placing her dentures in her mouth prior to eating breakfast. The licensed…

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 documentation review, the facility staff failed to provide incontinence care to one resident (resident #2- R2), in a survey sample of five residents. The findings included: On 7/25/24 at 12:18 p.m., the daughter of R2 met with the surveyors. The family member reported that she visits daily and stays for long periods of time because she has concerns about the facility staff not providing care to her mother. On 7/25/24 at approximately 3:55 p.m., the surveyor went to visit with R2. R2 was lying in bed and did not communicate or answer questions. The daughter of R2 was at the bedside and reported that from the time she arrived a little after 12 noon, until 3pm, no staff had entered her mother's room to provide any care. At 3 p.m., the family member went into the hall and sought out a staff member to assist with incontinence care of R2. During care, it was noted that R2 had saturated not only her incontinence brief, but her pants were visibly wet with urine all the way to the knees. The family member showed the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one resident (Resident #1- R1), in a survey sample of five residents. The findings included: For R1, the facility staff failed to maintain a complete clinical record with regards to the hospice services provided, including her death, which was pronounced by the hospice staff. On [DATE], a closed record review was conducted of R1's chart. This review revealed that the resident was admitted to the facility on [DATE] and discharged on [DATE]. R1 was admitted from an acute care hospital with the diagnosis to include, but not limited to, traumatic subdural hemorrhage and subarachnoid hemorrhage. According to the physician orders, on [DATE], an order was written for a hospice consult. On [DATE], another order was written, which noted a hospice company name. Within the clinical record there were no notes or details regarding hospice care, treatment, or involvement when R1 expired at the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to provide care for a PEG (percutaneous endoscopic gastrostomy) for one of nine residents in the survey sample (Resident #104). The findings include: There was no dressing applied to Resident #104's PEG tube site as required in the plan of care to prevent feeding tube complications. Resident #104 (R104) was admitted to the facility with diagnoses that included congestive heart failure, subarachnoid hemorrhage, hemiplegia, dysphagia with gastrostomy, hypertension, depression and anxiety. The minimum data set (MDS) dated [DATE] assessed R104 with moderately impaired cognitive skills. On 5/6/24 at 2:30 p.m., R104 was observed in bed with the abdomen uncovered and the feeding tube site visible. There was no dressing around R104's feeding tube with the insertion site exposed. No dislodged or old dressings were observed on or around the resident's bed. R104's clinical record documented a physician's order dated 3/10/24 to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration to one of nine residents in the survey sample (Resident #108). The findings include: Resident #108 was admitted to the facility with diagnoses that included deep vein thrombosis, metastatic cancer, hypertension, gastroenteritis, and cellulitis. The minimum data set (MDS) dated [DATE] assessed R108 as cognitively intact. R108's closed clinical record documented physician orders dated 3/11/24 for the following medications. Baclofen 5 mg (milligrams) two times per day for muscle spasms. Hydrocortisone ace-pramoxine external cream 2.5-1 % topically two times a day for treatment of separated foreskin. Potassium chloride crystals 20 milliequivalents (mEq) once daily for prevention of hypokalemia. R108's nursing notes documented the morning doses of Baclofen and the hydrocortisone ace-pramoxine cream were not available for administration on 3/12/24. Nursing…

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

Based on staff interview, clinical record review, and facility document review the facility failed to notify the responsibly party (RP) of a change in condition for one of 12 residents. The Findings Include: Resident #7 (R7) had a ground level fall, and the RP was not notified. According to the clinical record, diagnoses for R7 included peripheral vascular disease, diabetes, dementia, walking difficulty, and falls. The most current MDS (minimum data set - assessment tool) was an admission assessment with an ARD (assessment reference date) of 12/4/23. R7 was assessed with a cognitive score of 10 out of 15, indicating moderately impaired cognition. Review of a (late entry) progress note dated 1/16/24 noted . charge nurse placed residents bed in low position, resident then slid herself on the edge of the bed which this writer assist with lowering her to the floor unable to get the CNA [certified nursing assistant] on duty with assisting her back to bed, resident was able to hold to walker and stated I'm getting out of here The facilities progress notes documented that R7 was sent 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 staff interview, clinical record review, and facility document review, the facility failed to follow professional standards of practice for two of 12 residents (Resident 7 & Resident 9). 1. Assessments were not completed for Resident #7 (R7) after a fall. 2. A syringe with needle was not properly disposed of for R9. The Findings Include: 1. Assessments were not completed for Resident #7 (R7) after a fall. According to the clinical record, diagnoses for R7 included peripheral vascular disease, diabetes, dementia, walking difficulty, and falls. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 12/4/23. R7 was assessed with a cognitive score of 10 out of 15, indicating moderately impaired cognition. Review of a (late entry) progress note dated 1/16/24 noted . charge nurse placed residents bed in low position, resident then slid herself on the edge of the bed which this writer assist with lowering her to the floor unable to get the CNA [certified nursing assistant] on duty with assisting her back to bed, resident was…

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

Based on staff interview, and clinical record review, the facility failed to implement interventions for a skin condition for one of 12 residents (Resident #9). The Findings Include: Resident #9 (R9) did not have interventions for a skin rash to the groin area. According to the closed record review, diagnoses for R9 included diabetes, dementia, and abscess of right foot. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 1/26/23, which assessed R9 with a cognitive score of 13 out of 15, indicating intact cognition. Review of R9's Skin Observation Tool, dated 1/30/2023, 2/6/2023, and 2/10/2023 documented R9 had a Rash to the Groin. Review of the physician's orders did not evidence any interventions, including treatments, that were ordered for the rash. R9's care plan was also reviewed and did not show interventions for R9's rash. On 3/6/24 at 11:25 AM, license practical nurse (LPN #4, wound nurse) was interviewed. LPN #4 reviewed R9's clinical record and verbalized inability to evidence interventions for the rash and stated that…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility failed to administer tube feeding per physician order for one resident (Resident #12, R12) in a survey sample of 12 residents. The findings include: R12 did not receive the correct amount of tube feeding per physicain's orders. R12 was admitted to the facility on [DATE]. Diagnoses for R12 included but are not limited to hemiplegia, dysphagia, asthma and epilepsy. R12's minumum data set (MDS - assessment tool), dated 12/11/23, coded R12 with severe cognitive impairment. R12 needs extensive assistance from the staff with activities of daily living. On 3/4/24 at 4:10 p.m., observation was made of the tube feeding pump not being on, no feeding being given, the feeding tube was disconnected from R12, and hanging over the feeding pump. On 3/4/24 at 4:32 p.m., an interview was conducted with the licensed practical nurse (LPN#7). LPN#7 verbalized that R12 has a down time for 2 hours between the current bottle…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration to one of nine residents in the survey sample (Resident #108). The findings include: Resident #108 was admitted to the facility with diagnoses that included deep vein thrombosis, metastatic cancer, hypertension, gastroenteritis, and cellulitis. The minimum data set (MDS) dated [DATE] assessed R108 as cognitively intact. R108's closed clinical record documented physician orders dated 3/11/24 for the following medications. Baclofen 5 mg (milligrams) two times per day for muscle spasms. Hydrocortisone ace-pramoxine external cream 2.5-1 % topically two times a day for treatment of separated foreskin. Potassium chloride crystals 20 milliequivalents (mEq) once daily for prevention of hypokalemia. R108's nursing notes documented the morning doses of Baclofen and the hydrocortisone ace-pramoxine cream were not available for administration on 3/12/24. Nursing…

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

Based on resident interview, staff interview, and clinical record review, the facility staff failed to honor food preferences for one of twelve residents in the survey sample (Resident #6). The findings include: According to the clincal record, Resident #6 (R6) was admitted to the facility with diagnoses that included lymphedema, congestive heart failure, hypertension, atrial fibrillation, osteoarthritis, sleep apnea, rheumatoid arthritis, and morbid obesity. The most recent minimum data set (MDS - assessment tool) dated 12/2/23 assessed R6 as cognitively intact for daily decision making. On 3/5/24 at 11:40 a.m., R6 was interviewed about quality of care in the facility. R6 stated he was supposed to get a heart healthy, low sodium diet, but that meals had been served not according to preferences. R6 stated he had requested baked chicken without any seasoning for lunch and dinner and that regular chicken with seasonings had been served. R6 stated he wanted only eggs with toast for breakfast and had been served sausage for breakfast. R6 stated he had been served chicken salad 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 and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of twelve residents in the survey sample (Resident #6) The findings include: Resident #6's treatment administration records were incomplete and did not accurately document dressing changes. According to the clinical record, Resident #6 (R6) was admitted to the facility with diagnoses that included lymphedema, congestive heart failure, hypertension, atrial fibrillation, osteoarthritis, sleep apnea, rheumatoid arthritis, and morbid obesity. The minimum data set (MDS - assesment tool) dated 12/2/23 assessed R6 as cognitively intact for daily decision making. R6's clinical record documented the following physician orders: 10/30/22 - house stock moisturizer barrier cream to bilateral lower extremities daily. 2/8/24 - Cleanse left medial ankle with cleanser, apply Xeroform and calcium alginate, cover with bordered gauze 3 times per week until healed. 2/23/24 - Change bilateral Circaid wraps every day, inspect skin and apply lotion to legs. R6's treatment…

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

Based on observation, staff interview and facility document review, the facility staff failed to serve food in a sanitary manner. Hot food items were served from the steam table on unit 3 below the safe/recommended temperature of 135 degrees (F). Dietary staff entered the unit 3 kitchen during meal service without washing hands. A maintenance employee entered the unit 3 kitchen during food service without a hairnet. The findings include: On 9/6/22 at 12:16 p.m., lunch service from the unit 3 kitchen was observed. The dietary aide (other staff #2) placed trays of hot food on the steam table from a hot box. The dietary aide then left the kitchen stating he had to get a pen to record the food temperatures. The dietary aide returned a few minutes later, entered the kitchen and without prior hand hygiene, put on gloves. The food temperatures of items on the steam table measured by the dietary aide were as follows (in degrees F). shrimp stir-fry - 153 Salisbury steak - 155 steamed rice - 173 broccoli - 171 mixed vegetables - 137 mashed potatoes - 138 shredded/chopped shrimp - 105 pureed…

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

Based on observation, clinical record review, staff interview, and review of facility documents, the facility failed for one of 25 residents in the survey sample (Resident # 109) to provide a dignified dining experience. Staff were observed feeding Resident # 109 while standing next to him. The finding were: Resident # 109 was admitted with diagnoses that included Parkinson's Disease, history of COVID-19, macular degeneration, blindness left eye, benign prostatic hyperplasia, Vitamin-D deficiency, dysphagia, chronic prostatitis, psychotic disorder with hallucinations, difficulty in walking, and generalized muscle weakness. According to the most recent Minimum Data Set, a Quarterly Review, with an Assessment Reference Date of 8/29/2022, the resident was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making skills. At 12:30 p.m. on 9/7/2022, Resident # 109 was observed seated at a table in the Unit Four dining area. The resident was being fed by a Certified Nursing Assistant, later identified as CNA #…

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, the facility staff failed to document a DNR (DO NOT RESUSCITATE) status in the clinical record for one of 25 residents, Resident #93. Findings were: Resident #93 was admitted with the following diagnoses including but not limited to: COPD (chronic obstructive pulmonary disease), respiratory failure, abdominal aortic aneurysm, and hypertension. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assessed Resident #93 as cognitively intact with a summary score of 15. Resident #93 was interviewed on [DATE] at approximately 2:00 p.m. regarding life at the facility. In the course of the conversation she was asked if she had any advance directives in place. She stated that she had chosen to be a DNR. The clinical record was reviewed on [DATE] at approximately 2:45 p.m. There were no physician orders for resuscitation status observed in the clinical record. There were no directions regarding advance…

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 complaint investigation, clinical record review, and staff interview, the facility failed for resident of 25 residents in the survey sample (Resident # 112), to notify the resident's family of a change in condition. Resident # 112 suffered a change in mental status that was not communicated to the resident's family. The findings were: Resident # 112 was admitted with diagnoses that included Multiple Sclerosis, non-pressure chronic ulcer of left lower leg, arteriosclerosis, peripheral vascular disease, restless leg syndrome, protein-calorie malnutrition, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, iron deficiency anemia, acute ischemic heart disease, hypertension, anxiety disorder, history of malignant neoplasm of bronchus and lung, absence of (part) lung, and generalized muscle weakness. According to a Medicare 5-Day Minimum Data Set with an Assessment Reference Date of 3/11/2021, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact with a Summary Score of 15 out of 15. 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 and staff interview, the facility staff failed for one of 25 residents in the survey sample, to ensure the resident had a completed Preadmission Screening and Resident Review (PASARR). Resident # 109 did not have a PASARR completed at admission. The findings include: Resident # 109 was admitted with diagnoses that included Parkinson's Disease, history of COVID-19, macular degeneration, blindness left eye, benign prostatic hyperplasia, Vitamin-D deficiency, dysphagia, chronic prostatitis, psychotic disorder with hallucinations, difficulty in walking, and generalized muscle weakness. According to the most recent Minimum Data Set, a Quarterly Review, with an Assessment Reference Date of 8/29/2022, the resident was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making skills. A review of Resident # 109's Electronic Health Record (EHR) revealed the resident did not have a PASARR completed at admission.…

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 develop a baseline care plan for one of 25 residents in the survey sample. Resident #107 did not have a baseline care plan for a PICC (peripherally inserted central catheter) line. The Findings Include: Diagnoses for Resident #107 included: Acute respiratory failure, pneumonia, MRSA (methicillin resistant staphylococcus aureus), and diabetes. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 7/26/22. Resident #107's cognitive score was a 12 indicating moderately cognitively intact. Resident #107 was admitted to the facility on [DATE] On 9/06/22 at 3:45 PM an interview with Resident #107 was attempted. During the interview Resident #107 was asked about the PICC line observed in the right upper arm. Resident #107 verbalized she did not know what it was for. On 9/6/22 Resident #107 physician orders were reviewed and documented an order for 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 and clinical record review, the facility staff failed to develop a comprehensive care plan for two of twenty-five residents in the survey sample. Resident #102 had no care plan developed regarding diabetic management, anticoagulant use and epilepsy. Residents #22 had no individualized care plan for recreational activities. The findings include: 1. Resident #102 was admitted to the facility with diagnoses that included osteomyelitis, epilepsy, cellulitis, diabetes, MRSA (methicillin resistant staphylococcus aureus) infection, depression, hypertension, heart failure, history of cerebral infarction, and acute deep vein embolism/thrombosis of lower extremity. The minimum data set (MDS) dated [DATE] assessed Resident #102 as cognitively intact. On 9/7/22 at 8:00 a.m., Resident #102 was interviewed about quality of care in the facility. Resident #102 stated she received blood sugar checks and insulin daily. The resident stated she was also prescribed a blood thinner and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, facility document review and during the course of a complaint investigation, the facility staff failed to review and revise the CCP (comprehensive care plan) for one of 25 residents in the survey sample. Resident #111's CCP was not reviewed and revised for adequate fall interventions and/or supervision for the prevention of falls. Findings include: Resident #111's CCP was not reviewed and revised for adequate fall interventions and/or supervision for the prevention of falls. Resident #111's diagnoses included, but were not limited to: ataxia [impaired coordination] following a non-traumatic intracerebral hemorrhage, myelodysplastic syndrome, pancytopenia, headache, anemia, cognitive communication deficit, abnormalities of gait and mobility, lack of coordination, dysphagia, mild protein calorie malnutrition, high blood pressure, atrial fibrillation, vertigo (dizziness) and fracture of right femur. The most recent full MDS (minimum data set) was an admission…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to respond to a pharmacy recommendation for one of twenty-five residents in the survey sample. Resident #57's recommendation regarding continued use of antibiotics had no physician response. The findings include: Resident #57 was admitted to the facility with diagnoses that included prostate cancer, anemia, protein-calorie malnutrition, emphysema, heart failure, COPD (chronic obstructive pulmonary disease), depression, anxiety, obstructive uropathy, bladder cancer and chronic pain. The minimum data set (MDS) dated [DATE] assessed Resident #57 as cognitively intact. Resident #57's clinical record documented a pharmacy recommendation dated 6/29/22 documenting the following, This resident is on this Azithromycin and Bactrim DS since 6/20/22 without stop date. Prolonged use of antimicrobial agents can result in superinfection. Please indicate below the duration of therapy or reasons for continual usage . 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 and staff interview, the facility failed to ensure one of 22 residents in the survey sample was free of unnecessary psychotropic medications. Resident #56 had physician orders for as needed (PRN) psychotropic medications that extended for more than 14 days without a stop date. The findings include: Resident #56 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, hyperlipidemia, colostomy, muscle weakness, hypertension, hypothyroidism, and encounter for palliative care - hospice. The most recent minimum data set (MDS) dated [DATE] which was a quarterly assessment, assessed Resident #56 as severely cognitive impaired for daily decision making with a score of 4 out of 15. On 03/17/2021 Resident #56's clinical record was reviewed. Observed on the physician order sheet was the following: Ativan Tablet 0.5 MG (milligrams) (LORazepam) Give 1 tablet by mouth every 6 hours as needed 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 observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not readily available for distribution on the 200 unit and 300 unit, and failed to label an open vial of insulin on the 400 unit. The findings include: 1. On 03/17/2021 at 7:37 a.m. medication storage observations were conducted on the 300 all RN #1 (registered nurse). Observed on the 300 long hall medication cart were the following opened bottle of medications: 1. Rugby Vitamin B-12 1000 mcg (microgram) supplement 100 tablets, open date 9/8/20, expiration date 4/20. 2. Sunmark Loratadine 10 mg (milligram) antihistamine 90 tablets, open date 1/2/20, expiration date 11/20. 3. Gericare Theratabs High Potency Multivitamin formula 100 caplets, open date 8/9/20, expiration date 7/20. 4. Gericare Extra Strength Simethicone Gas Relief 125 mg (milligrams) 30 tablets, open date 8/1/20, expiration date 12/20. On 03/17/2021 at 8:02 a.m., RN #1 was interviewed regarding expiration medication. RN #1 stated, we are supposed to complete random checks for expired meds,…

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 policy review, facility staff failed to store food in a sanitary manner in the main kitchen. Findings included: On 03/16/21 at 10:30 A.M. an initial tour of the main kitchen was conducted along with the dietary manager (other staff, OS #2). The walk in refrigerator was observed. An opened packet of a partial whole ham had no label indicating open or expiration date. A container of cooked egg noodles was open to air (not covered) and without a label. OS #2 was asked about the open container of egg noodles. OS #2 stated a larger pan of egg noodles had fallen and the staff had picked up the egg noodles and placed them into the small container and they should have been thrown away. The reach in refrigerator was then observed. A packet of sausage patties were open without a label indicating an open or expiration date, and a packet of sliced ham was also opened without a label. OS #2 stated that the packages should have labels on them. A Refrigerator Food Storage Schedule was attached to the front of the walk in refrigerator 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 observation, staff interview, and facility document review, the facility staff failed to follow infection prevention control practices during communal dining on one of four units, unit 4. The findings include: On 3/16/2021 at 12:15 PM, 14 residents were observed seated in the 400 hall dining room during the lunch time meal. All residents were seated either across from each other or adjacent to each and were approximately less than six feet apart. Additionally, some dining room tables were positioned such that the resident's dining chair/wheelchair backs were nearly touching the backs of the chairs to the tables behind them. On 3/16/2021 at 12:35 PM, certified nursing assistant (CNA #9), who assisted in the 400 hall dining room during the observation, was interviewed regarding social distancing requirements for communal dining. CNA #9 stated that since everyone had gotten the second COVID vaccine, she was told they could start bringing the resident's into the dining room, with 2 at a table, and that although the resident's that were sitting adjacent to each other were not…

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 obtain physician orders for immediate care for one of 22 residents in the survey sample. Resident #142 had no physician orders upon admission for care of pressure ulcers, impaired skin integrity, and monitoring of a dialysis access port. The findings include: Resident #142 was admitted to the facility on [DATE] with diagnoses that included pancreatitis, end stage renal disease with hemodialysis, depression, atherosclerotic heart disease, bullous pemphigoid, anxiety, diabetes, hypertension, atrial flutter, anemia and hip fracture. The admission assessment dated [DATE] assessed Resident #142 as alert, oriented to person with confusion and short-term memory problems. This assessment listed the resident as incontinent of bowel/bladder and as requiring physical assistance of two people for bed mobility and totally dependent upon staff for transfers. Resident #142's clinical record documented a skin assessment dated [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility staff failed to ensure an accurate MDS (minimum data set) assessment for one of 22 residents in the survey sample, Resident #9. Findings include: Resident #9 was admitted to the facility on [DATE]. Diagnoses for Resident #9 included, but were not limited to: CHF (congestive heart failure), PVD (peripheral vascular disease), history of stroke, dementia, malnutrition and depression. The most current MDS, a quarterly assessment dated [DATE] assessed the resident with a cognitive score of 7, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as requiring limited assistance from at least one staff for most all ADLs (activities of daily living) and set up only for eating. This MDS also assessed the resident in Section K0300. as having a 5% weight loss in the last month or 10% weight loss in the last 6 months (not physician prescribed), and in Section K0310. assessed the resident as having a 5%…

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 failed to develop a baseline care plan for one of 22 residents in the survey sample, Resident #142. Resident #142's baseline care plan failed the include pressure ulcers, impaired skin integrity, fall/injury prevention, and anticoagulant use. The findings include: Resident #142 was admitted to the facility on [DATE] with diagnoses that included pancreatitis, end stage renal disease with hemodialysis, depression, atherosclerotic heart disease, bullous pemphigoid, anxiety, diabetes, hypertension, atrial flutter, anemia and hip fracture. The admission assessment dated [DATE] assessed Resident #142 as alert, oriented to person with confusion and short-term memory problems. This assessment listed the resident as incontinent of bowel/bladder and as requiring physical assistance of two people for bed mobility and totally dependent upon staff for transfers. Resident #142's clinical record documented an admission skin assessment dated [DATE].…

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

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 follow professional standards of practice during medication administration for one of 22 residents, Resident #18. The findings include: Resident #18 was admitted to the facility on [DATE]. Diagnoses for Resident #18 included but was not limited to: Unspecified Dementia without behavioral disturbance, Heart failure, Chronic Atrial Fibrillation, Mild cognitive impairment, and Acute follicular conjunctivitis, left eye. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/24/20. Resident #18 was assessed with a cognitive score of 06 indicating severe cognitive impairment. On 3/16/2021 at 10:40 AM, upon entering Resident #18's room, a medicine cup with several pills in it and a bottle of prescription nasal spray were observed on resident #18's bedside table. When asked about the medications, Resident #18 stated she was waiting for someone…

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 failed to follow physician orders for protective arm sleeves for one of 22 resident's, Resident #8. The Findings Include: Resident #8 was admitted to the facility on [DATE]. Diagnoses for Resident #8 included: Cellulitis, diabetes, neuropathy and dementia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/5/20. Resident #8 was assessed with a cognitive score of 5 indicating severe cognitive impairment. On 03/16/21, Resident #8's medical record was reviewed. An active physician's order, originally dated 11/24/20 documented Tubi grip [arm protectors] to both forearms Q [every] shift for protection [ .] Resident #8's current care plan included a care plan regarding skin impairment. An intervention dated 11/25/20 read Tubi Grip sleeves to BUE [bilateral upper extremity]. On 03/16/21 at 10:58 AM, Resident #8 was interviewed. During the interview Resident #8's arms were…

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 assess and provide care/treatment to pressure ulcers for one of 22 residents in the survey sample, Resident #142. Resident #142, assessed with pressure ulcers upon admission to the facility, had no assessment and interventions implemented for care/treatment of the wounds. The findings include: Resident #142 was admitted to the facility on [DATE] with diagnoses that included pancreatitis, end stage renal disease with hemodialysis, depression, atherosclerotic heart disease, bullous pemphigoid, anxiety, diabetes, hypertension, atrial flutter, anemia and hip fracture. The admission assessment dated [DATE] assessed Resident #142 as alert, oriented to person with confusion and short-term memory problems. This assessment listed the resident as incontinent of bowel/bladder and as requiring physical assistance of two people for bed mobility and totally dependent upon staff for transfers. 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, facility document review and clinical record review, the facility staff failed to ensure infection control practices were followed for a Foley catheter for one of 22 residents in the survey sample, Resident #54. Findings include: Resident #54 was admitted to the facility on [DATE]. Diagnoses for Resident #54 included, but were not limited to: pneumonia, sleep apnea, altered mental status, anxiety disorder, depression, thyroid disorder, high blood pressure, history of stroke, seizure disorder and urinary retention. The most current full MDS (minimum data set) was a significant change assessment dated [DATE]. The resident was assessed as having short and long term memory impairment with severe impairment in daily decision making skills. The resident was assessed to require extensive to total assistance for all ADLs (activities of daily living). The resident was assessed as having a catheter on this MDS. On 03/16/21 at 12:20 PM, Resident #54 was sitting in a geri chair…

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 monitor a dialysis access port for one of 22 residents in the survey sample. For four days after admission, facility staff failed to assess Resident #142's dialysis access port for complications. The findings include: Resident #142 was admitted to the facility on [DATE] with diagnoses that included pancreatitis, end stage renal disease with hemodialysis, depression, atherosclerotic heart disease, bullous pemphigoid, anxiety, diabetes, hypertension, atrial flutter, anemia and hip fracture. The admission assessment dated [DATE] assessed Resident #142 as alert, oriented to person with confusion and short-term memory problems. This assessment listed the resident as incontinent of bowel/bladder and as requiring physical assistance of two people for bed mobility and totally dependent upon staff for transfers. Resident #142's clinical record documented an admission assessment dated [DATE] listing the resident had a catheter…

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 maintain a complete and accurate clinical record for one of 22 residents, Resident #188. An After Visit Summary dated [DATE] was not completely scanned into the electronic record. Page one of the summary was identified on the bottom of the page as Page 1 of 6. The remaining five pages were not in the clinical record. Findings were: Resident #188 was admitted to the facility on [DATE] following an approximate two month stay at a local hospital. Her diagnoses included, but were not limited to: Necrotizing faciitis with GBS (Group B Streptococcus), Cardiomyopathy with ejection fraction of 18% with ICD (implantable cardioverter defibrillator) in place and stents, diabetes mellitus, hypertension, Foley catheter (wound protection), loop colostomy (wound protection), morbid obesity and moderate protein calorie malnutrition. The admission MDS (minimum data set) with an ARD (assessment reference date) of [DATE], assessed Resident #188 as…

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.