Cedars Healthcare Center

2. The facility staff failed to notify all required agencies of an allegation of abuse that involved R11 and certified nursing assistant, CNA#3. On 11/21/24 a review of facility documentation was conducted, which includent the incident summary and the facility synopsis of an allegation of abuse that involved R11 and CNA#3. No documentation was found that showed that the Virginia Department of Health professions (DHP) was notified of the determination of abuse that involved a certified nursing assistant, identified as CNA3. While the incident summary was completed on 9/15/24. the facility fax confirmation read, no answer, for the DHP on 9/16/24 and 9/19/24, On 11/21/24 at 2:00 p.m., an interview was conducted with the administrator. The Administrator said, Sometimes the fax numbers are busy, and we have to keep faxing. The Administrator was not able to show that the incident had been successfully faxed to fulfill the required abuse reporting. On 11/22/24 a review of facility documentation was completed. CNA#3's employee file was reviewed and there was no sworn statement or criminal…

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 documentation review, the facility staff failed to provide credible evidence of an investigation being conducted following an allegation of sexual abuse for one resident (Resident #120-R120) in a survey sample of 30 residents. The findings included: For Resident #120- R120, who made an allegation of being raped, the facility staff failed to have credible evidence of an investigation being conducted. On 11/20/24, the surveyor reviewed the facility documentation and electronic health record of R120, which noted that R120 discharged from the facility on 9/20/24. According to progress notes dated 9/20/24, which read in part, .Patient had a recent ECO [emergency custody order] for similar symptoms, primarily mania. Due to her current mental status, she likely does not have capacity to make appropriate medical decisions for herself. Because of patient's severe psychiatric symptoms, her interfering with staffs' ability to provide care to herself and others, and her creation of a hostile environment, she would be best served by…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility failed to develop a care plan for one of thirty one residents. Resident #5 (R5) did not have a complete care plan developed for incontinence. The Findings Included Review of R5's clinical record noted diagnoses for R5 included incontinence of bowel and bladder, chronic congestive heart failure, and chronic atrial fibrillation. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 9/27/24, which assessed R5 with a cognitive score of 14 out of 15, indicating cognitively intact. On 11/19/24 at 11:41 a.m. during an interview, R5 verbalized having incontinent episodes and that the staff did a good job at keeping her clean and dry. Review of R5's MDS dated [DATE], Section H - Bowel and Bladder, documented that R5 was Always Incontinent of bowel and bladder. Review of R5's care plan did not indicate a care plan had been developed for incontinence. On 11/21/24 at 11:54 a.m., license practical nurse…

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

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide respiratory care for three residents, Resident #77 (R77), Resident #83 (R83), and Resident #5 (R5) out of a survey sample of 30 residents. The findings included: 1. The facility staff failed to administer oxygen to R77, according to the physician's order. On 11/20/24 at 9:20 a.m., an interview was conducted with R77. R77 said, Staff says all concentrators are broken and sometimes at night I am short of breath. At this time, it was observed that R77's oxygen concentrator setting was on 2.5 liters per minute. On 11/20/24 at 11:00 a.m., a review of R77's clinical record was conducted. The clinical record revealed that R77's physician's order was for oxygen therapy at 5 liters per min via tracheostomy mask every shift for hypercarbia. On 11/20/24 12:22 p.m., an interview was conducted with a licensed practical nurse, LPN5. LPN5 read the physician's order for R77's oxygen and stated that the setting should be at 5 liters per minute.…

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 percent. Medication pass observations resulted in two errors out of thirty opportunities for an error rate of 6.67%. The findings include: 1. R274 was not administered a dose of gentamicin eye drops as ordered by the physician. A medication pass observation was conducted on 11/20/24 at 8:07 a.m. with registered nurse (RN #1) observed administering medications to Resident #274 (R274). R274 was administered all scheduled medications except gentamicin eye drops. RN #1 searched the medication cart and did not locate the drops. RN #1 stated the gentamicin eye drops were not available and that she would contact the pharmacy. R274's clinical record documented a physician's order dated 11/14/24 for gentamicin sulfate ophthalmic solution 0.3% with instructions to instill one drop in the left eye two times per day for 6 months. R274's medication administration record documented the drops were scheduled for administration each morning and evening. On…

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

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide routine dental services to two residents (Resident #80-R80 and Resident #4-R4) in a survey sample of 30 residents. The findings included: 1. For R80, the facility staff failed to provide dental services following a recommendation for extractions. On 11/19/24 at 11:24 a.m., an interview was conducted with R80. R80 stated he is unable to eat because of his teeth and cancer and relies solely on nutritional drinks. When asked about his dental status, R80 said that he had gone to a dental clinic but was unable to be seen due to having expired identification. On 11/20/24, a clinical record review of R80's chart was conducted. According to a physician progress note dated 11/7/24, R80 was s/p [status post] antineoplastic chemotherapy and had a history of synovial sarcoma who had complications of dysphagia related to the pharyngeal/cervical mass . According to R80's dental services note dated 4/3/23, R80 was seen and the note read in part, Recommend…

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 ensure a therapeutic diet and correctly provide foods per the meal ticket for one of thirty residents in the survey samplec, (Residents #103). Resident #103 (R103) was not provided foods per meal ticket for lunch. The findings include: According to the clinical record, diagnoses for R103 included severe protein calorie malnutrition, dementia, and iron deficiency anemia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 10/31/24. R103 was assessed with a cognitive score of 12 out of 15, indicating intact cognition. An annual MDS, dated [DATE], Section K documented that R103 had un-prescribed weight loss. On 11/19/24 at 12:45 p.m., R103 lunch meal was observed, R103's meal ticket was verified against the meal served. The meal ticket indicated R103 was to receive a regular advanced dysphagia diet, with an added half cup of fortified pudding parfait and a bowl 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, resident interview, staff interview and clinical record review, the facility staff failed to honor food preferences for one of thirty residents in the survey sample (Resident #93). The findings include: Resident #93 was not provided a fruit salad as listed on the meal ticket and according to assessed food preferences. According to the clincal record, Resident #93 (R93) was admitted to the facility with diagnoses that included spinal stenosis, bradycardia, sick sinus syndrome, hypertension, neurogenic bladder, depression and insomnia. The minimum data set (MDS) dated [DATE] assessed R93 as cognitively intact. On 11/19/24 at 11:38 a.m., R93 was interviewed about quality of life/care in the facility. R93 stated that he was supposed to get a fruit salad each day for lunch and that he never gets the fruit. R93's clinical record documented the resident was prescribed a regular diet. A food preference assessment dated [DATE] listed that R93 liked/preferred fresh fruit. On 11/20/24 at 12:32 p.m.,…

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 ensure an accurate clinical record for one of thirty residents in the survey sample (Resident #94). The findings include: Resident #94's clinical record included documented hospice notes for three other residents (Residents #10, #26 and #101). According to the clinical record, Resident #94 (R94) was admitted to the facility with diagnoses that included diabetes, adult failure-to-thrive, protein-calorie malnutrition, chronic kidney disease, anxiety, and depression. The minimum data set (MDS) dated [DATE] assessed R94 with having short and long-term memory problems and severely impaired cognitive skills. Review of R94's clinical record revealed documentation regarding hospice care/services. Included in R94's clinical record were hospice notes/documentation for three other current residents in the facility, who were also receiving hospice services. The other residents' notes scanned into R94's clinical record were as follows: Resident…

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

Based on observation, staff interview, and facility document review, the facility staff failed to follow infection control practices during medication pass and pour observation on one of two units. The findings include: License practical nurse (LPN #1) was observed handling medications with cross contaminated gloved hands, during medication pass on unit 400. on 11/20/24 at 8:00 a.m., during a medication pass for Resident #15 (R15), LPN #1 (LPN1)was observed sanitizing her hands and applying gloves. Then LPN1 began using the computer to view information, before reaching into the medication cart draw to pull out needed medications (consisting of bulk bottled medications and medication card packs). LPN1 started popping medications into her hand, reaching into bulk bottled medications with her fingers, and placing the medications into the medication cup, before distributing the medications to R15. After giving medications to R15, LPN #1 then pushed the medication cart to R42's room, sanitized her hands, applied gloves, and again used the computer, placed hands on the table top 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.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to educate about and offer COVID-19 immunizations according to the facility's infection control policy for two of five residents reviewed (Residents #20 and #94). The findings include: On 11/21/24 at 11:45 a.m., accompanied by the regional infection preventionist (RN #2), five residents were reviewed for immunizations as part of the infection control survey task. Review of clinical records revealed no documentation of COVID-19 immunization status for Residents #20 and #94. The clinical records documented no education about or offering of the COVID-19 vaccine since their admission to the facility. On 11/21/24 at 2:09 p.m., the regional infection preventionist (RN #2) stated that she reviewed the clinical records and did not find any evidence Residents #20 or #94 had been offered the COVID-19 vaccine. The regional infection preventionist stated immunization status was supposed to be obtained upon admission to the facility and vaccines offered if not already received. The…

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

Based on observations, resident interview, staff interview, and facility document review, the facility staff failed to ensure oxygen concentrators were in proper working condition for one resident, Resident #77 (R77) out of a survey sample of 30 residents. The findings included: The facility staff failed to provide an oxygen concentrator that would administer the ordered liters of oxygen. On 11/20/24 at 9:20 a.m., an interview was conducted with R77. R77 said, Staff says all concentrators are broken and sometimes at night I am short of breath. At this time, it was observed that R77's oxygen concentrator setting was on 2.5 liters per minute. On 11/20/24 at 11:00 a.m., a review of R77's clinical record was conducted. The clinical record revealed that R77's physician's order was for oxygen therapy at 5 liters per min via tracheostomy mask every shift for hypercarbia. On 11/20/24 12:22 p.m., an interview was conducted with a licensed practical nurse, LPN5. LPN5 read the physician's order for R77's oxygen and stated that the setting should be at 5 liters per minute. Accompanying the…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for one of nine residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to implement the resident's comprehensive care plan for pressure injury treatments. R4's comprehensive care plan dated 9/6/23 documented, Resident with potential impaired skin integrity or actual impaired skin integrity r/t (related to) pressure ulcer to right heel .Treatments as ordered .Left Achillies wound on admission 3/05/24 .TX (Treatment) as ordered . A review of R4's clinical record revealed the following physician's orders: 2/27/24-cleanse the stage three right heel wound with wound cleanser. Apply silvasorb gel to the wound bed and cover with gauze, ABD (wound dressing), and rolled gauze daily. 3/5/24-cleanse the left Achillies wound with wound cleanser, apply silvasorb, abd, kerlix every day. A wound physician note dated 5/7/24 documented a stage three right heel pressure injury measuring 1.9 cm…

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/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide incontinence care for dependent residents for three of nine residents, Resident #3, Resident #6 and #7. The findings include: 1.The facility staff failed to provide evidence of incontinence care for dependent Resident #3. Resident #3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), COPD (chronic obstructive pulmonary disease), congestive heart failure and encephalopathy. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 12/31/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to maintain residents' highest level of well-being for two of nine residents in the survey sample, Residents #4 and #5. The findings include: 1. For Resident #4 (R4), the facility staff failed to provide physician ordered treatments for the resident's arterial wound on multiple dates in May 2024. A review of R4's clinical record revealed a physician's order dated 4/23/24 to cleanse the arterial left lateral heel with wound cleanser, apply silvasorb, gauze, abd pad (wound dressing), kerlix and ace wrap every day. A wound physician note dated 5/7/24 documented the wound as an arterial left lateral heel wound measuring 1.2 cm (centimeters) (length) x 1 cm (width) x 0.1 cm (depth). A review of R4's May 2024 TAR (treatment administration record) revealed the same physician's order. Further review of R4's May 2024 TAR failed to reveal treatment was administered on 5/11/24, 5/16/24, 5/18/24, and 5/26/24 (as evidenced by blank spaces on the TAR). Nurses'…

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

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for the treatment of pressure injuries for one of nine residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to provide physician ordered treatments for the resident's stage three right heel pressure injury (1) and stage four left Achillies pressure injury (1) on multiple dates in May 2024. A review of R4's clinical record revealed the following physician's orders: 2/27/24-cleanse the stage three right heel wound with wound cleanser. Apply silvasorb gel to the wound bed and cover with gauze, ABD (wound dressing), and rolled gauze daily. 3/5/24-cleanse the left Achillies wound with wound cleanser, apply silvasorb, abd, kerlix every day. A wound physician note dated 5/7/24 documented a stage three right heel pressure injury measuring 1.9 cm (centimeters) (length) x 2.2 cm (width) x 0.5 cm (depth), with 75-99% slough (dead skin tissue) and a stage four left Achilles pressure injury measuring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a safe environment by monitoring the wander guard for one of nine residents, Residents #9. The findings include: During the abbreviated complaint survey 8/14/24 through 8/16/24 review of the facility event synopsis, the elopement of Resident #9 on 6/30/24 was reviewed. Resident #9 was admitted to the facility on [DATE] with diagnosis that included but were not limited to dementia, hypertension and macular degeneration. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/6/24, coded the resident as scoring a 04 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and supervision for eating. 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 resident/staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a safe environment for one of nine residents, Resident #3. The findings include: The facility staff failed to ensure a safe environment for Resident #3. According to the clinical record, Resident #3 (R3) was admitted to the facility on [DATE] with diagnosis that included, but were not limited to, trach, hypertension, and psychoactive substance abuse. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 6/27/24, coded R3 as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating intact cognition. A review of the MDS (minimum data set) Section GG-functional abilities and goals coded R3 as being independent for walking/bathing/transfer/dressing/toileting, and eating. A review of R3's comprehensive care plan with a revision date of 1/5/23, revealed, FOCUS: Resident 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 review of facility's documentation and staff interview, it was determined that the facility failed to allow the resident to make decisions regarding her treatment for one of nine residents, Resident #2. The findings included: The facility failed to allow the resident to make decisions regarding her treatment. Resident #2 was admitted to the facility on [DATE] with diagnosis that included but were not limited to encephalopathy, COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure) and DM (diabetes mellitus). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 12/31/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer, bathing, bed mobility, dressing, hygiene and supervision for eating. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident/staff interview, facility document review, and clinical record review, the facility staff failed to report an allegation of resident who was on the roof with potential for self-harm for 1 of 9 residents, Resident #3. The findings include: The facility failed to report an allegation that a resident was on the roof with potential for self-harm, Resident #3. Resident #3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to trach, hypertension and psychoactive substance abuse. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 6/27/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating Resident #3 was cognitively intact. A review of the MDS Section GG-functional abilities and goals coded Resident #3 (R3) as being independent for walking/bathing/transfer/dressing/toileting, and eating. A review of R3 comprehensive care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide treatment and services for one of nine resident's indwelling catheter, Residents #1. The findings include: The facility staff failed to provide treatment and services for Resident #1's indwelling catheter. Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to toxic encephalopathy, obstructive/reflux uropathy and neuromuscular dysfunction of the bladder. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 6/16/24, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to ensure dignity and respect for one resident. Resident #1's (R1) personal belongs were removed and staff did not leave room after being asked. The Findings Include: Diagnoses for R1 included: Congestive heart failure, anxiety, depression, and chronic obstructive pulmonary disease. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 10/4/23. R1 was assessed with a cognitive score of 14 out of 15, indicating intact cognition. Review of R1's clinical record documented a progress note dated 9/22/23, written by the administrator, indicating that R1 was selling food and beverages in the hallway and that it was explained to R1 that the practice of selling food was not allowed due to the diet orders of other residents. This note documented that food and beverage items were removed from the resident's possession, and that family had…

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 council interview, staff interview and facility document review, the facility staff failed to response promptly to call bells on three of four nursing units (100-unit, 200-unit and 300-unit). The findings include: On 9/11/23 at 4:00 p.m., eleven members of the facility's resident council were interviewed about call bell response. Resident #5 stated slow call bell response was an ongoing problem in the facility, especially on weekends. The other council members agreed with Resident #5 and described wait times from 15 minutes up to an hour. Resident #5 stated the poor call bell response had been a problem for months and had been discussed in monthly council meetings. Resident #5 stated there were times when only one aide was assigned to work on a unit and response times were slow because staff had to cover from another unit. Resident #5 stated she had experienced an incontinence accident because she was unable to hold her urine while waiting for assistance. Resident #6 stated she also waited at times beyond 15 minutes for her brief to be changed. Resident #7 stated…

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 a registered nurse (RN) at least eight consecutive hours per day for four out of thirty days in September 2022. The findings include: The facility's PBJ (payroll based journal) data for September 2022 documented no RN coverage was provided on 9/5/22, 9/10/22, 9/11/22 and 9/25/22. The facility's as-worked schedule documented no RN working on these dates. On 9/12/23 at 8:45 a.m., the director of nursing (DON) was interviewed about the lack of RN coverage during September 2022. The DON stated she had been working in the facility since April 2023 and registered nurses had been hired since September 2022 to meet the coverage requirement. The DON stated the RN coverage requirement was being met with currently employed registered nurses and contracted staff were also available if needed. On 9/12/23 at 11:42 a.m., the administrator was interviewed about RN coverage. The administrator reviewed the payroll records and confirmed that no RN worked on 9/5/22, 9/10/22, 9/11/22 and 9/25/22. On 9/12/23 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and during the course of a complaint investigation, the facility staff failed to ensure reasonable care and protection of resident property from loss and/or theft for one of 27 residents (Resident #10) regarding an iPad and a framed painting; and failed to ensure a safe homelike environment for one of 27 residents (Resident #21) regarding the resident's room, room equipment and room furnishings. Findings include: 1. Resident #10 was admitted to the facility originally on 12/13/19, with the most current readmission on [DATE]. Diagnoses for Resident #10 included, but were not limited to: repeated falls, conversion disorder with seizures, narcolepsy, history of a stroke with left side paralysis, major depressive disorder, cognitive communication deficit, and dementia without behaviors. The most current MDS (minimum data set) was a quarterly assessment dated [DATE], which assessed the resident with a cognitive score of 15, indicating the resident…

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

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 review and revise a care plan for four of 27 residents in the survey sample, and failed to ensure residents were extended an invitation to the care plan meetings and active participation from the facility's required interdisciplinary team members for two of 27 residents in the survey sample. Resident #24, Resident #75, and Resident #21 care plans were not reviewed and revised regarding code status changes and Resident #35's care plan was not reviewed regarding medication changes. Resident #94 and Resident #12 were not extended invitations to the care plans meetings and facility's required interdisciplinary team members did not actively participate in the care plan meetings. The findings include: 1. Resident #24 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia with behavioral disturbance, muscle contractures, anemia, hyperlipidemia, dysphasia,…

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 failed to ensure glasses were ordered to maintain vision for two of 27 residents, Resident's #12 and #94. The Findings Include: 1. Resident #12 was admitted to the facility on [DATE]. Diagnoses for Resident #12 included: Congestive heart failure, kidney disease, anxiety, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/25/21. Resident #12 was assessed with a cognitive score of 15 indicating cognitively intact. Section B of the current MDS documented Resident #12's vision was adequate with corrective lenses. On 06/22/21 at 12:21 PM. Resident #12 was interviewed. During the interview, Resident #12 discussed that she had an eye exam about a year ago and she was supposed to receive new glasses but never did get them. Resident #12's glasses were observed to have scratches on the lenes only one ear piece. On 06/23/21 at 9:41 AM, the social…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to ensure effective pest control in the facility for two resident rooms on the 400 unit (room [ROOM NUMBER] and 413), and in the hallway on the 400 unit, where gnats were observed; and failed to ensure effective pest control for flies and gnats observed in room [ROOM NUMBER] and 120 and 100 unit area. Findings include: Resident #35 (a resident with a cognitive score of 15) was interviewed on 06/22/21 at approximately 11:00 AM. The resident had his bedside table over him with a banana peel laying on the table. Several gnats were observed on the banana peel. Resident #35 was made aware of the gnats. The resident stated, Where? Resident #35 stated that he couldn't see very well and that he had poor vision and couldn't see the gnats. On 06/23/21 at 8:20 AM, Resident #35 was observed for a dressing change. The resident's physician was in the room performing a debridement of the resident's wound. Gnats…

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 promote dignity and respect for one of 27 residents in the survey sample, Resident #43. Facility staff provided incontinence care and a bed linen change while the resident was verbally refusing the care. The findings include: Resident #43 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, atherosclerotic heart disease, heart failure, diabetes, cellulitis, anemia, peripheral vascular disease, major depressive disorder, left eye blindness and peripheral neuropathy. The minimum data set (MDS) dated [DATE] assessed Resident #43 with moderately impaired cognitive skills, as frequently incontinent of bladder, with little interests in doing things and having feelings of being down, depressed and/or hopeless. The MDS dated [DATE] documented the resident required the extensive assistance of two people for bed mobility and the extensive…

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

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 accessible light switch for one of 27 residents in the survey sample, Resident #21. Resident #21's over-bed light was not equipped with a cord so the resident could turn the light on/off as desired. The findings include: Resident #21 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #21 included right shoulder/hand contracture, spinal stenosis, dysphagia, hypertension, dementia with behaviors, congestive heart failure, lymphedema, seizures, osteoarthritis, cerebral infarction and neuropathy. The minimum data set (MDS) dated [DATE] assessed Resident #21 with moderately impaired cognitive skills and adequate vision (sees fine details). On 6/22/21 at 12:45 p.m., Resident #21 was observed in his room and was interviewed at this time about quality of care and life in the facility. The resident stated he was not able to turn his over-bed light on/off…

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 ensure a complete minimum data set (MDS) for two of 27 residents in the survey sample. MDS assessments for Resident #32 and #43 were incomplete with no indicators of cognitive status or mood. The findings include: 1. Resident #43 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, atherosclerotic heart disease, heart failure, diabetes, cellulitis, anemia, peripheral vascular disease, major depressive disorder, left eye blindness and peripheral neuropathy. The minimum data set (MDS) dated [DATE] assessed Resident #43 with moderately impaired cognitive skills, with little interests in doing things and having feelings of being down, depressed and/or hopeless. Resident #43's clinical record documented an annual MDS dated [DATE]. Sections C for cognitive patterns and section D for mood indicators were not completed. The interview questions and assessment indicators were marked as not assessed or…

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

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 necessary care and treatment to prevent infection during a dressing change for one of 27 residents (Resident #35). Findings include: Resident #35 was admitted to the facility on [DATE], with the most recent readmission on [DATE]. Diagnoses for Resident #35 included, but were not limited to: muscle weakness, muscle wasting, atrophy, weakness, chronic pain, diabetes, heart failure and stage 4 pressure ulcer. The most current MD (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive status of 15, indicating the resident was intact for daily decision making skills. This MDS also assessed the resident with a stage 4 pressure ulcer that was present upon admission. During an interview with Resident #35 on 06/22/21 at approximately 11:00 AM. Resident #35 was asked about his pressure ulcer. The resident stated that was what brought him into the facility and that he…

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 medication pass observation, staff interview, and clinical record review, the facility failed to ensure medications were available for one of 27 residents, Resident #61. Resident #61 did not have Lactulose solution (for treatment of constipation and liver disease) available to give during the morning medication pass. The findings include: Resident #61 was admitted to the facility on [DATE] with a readmission on [DATE]. Diagnoses for Resident #61 included: Chronic obstructive pulmonary disease, schizoaffective disorder, chronic kidney disease, viral hepatitis C, and constipation. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 5/1/21. Resident #61 was assessed with a cognitive score of 12 indicating cognitively intact. On 6/23/21 at 8:10 AM, during medication pass and pour, license practical nurse (LPN #1 ) began pulling medications for Resident #61. LPN #1 said Resident #61's Lactulose was not on the cart and was going to check in 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 27 in the survey sample, Resident #109 and Resident #481. The findings include: 1. Resident #109 was admitted to the facility on [DATE] with diagnoses that included paraplegia, surgical wound aftercare, osteomyelitis, multiple pressure wounds, muscle weakness, anemia, Vitamin B-12 deficiency, and embolism and thrombosis of veins. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #109 as cognitively intact for daily decision making with a score of 15 out of 15. On 06/22/21 at 12:28 p.m., Resident #109 was observed in his room watching television. Resident #109 was interviewed regarding his quality of care since being admitted to the facility. Resident #109 stated, one of my biggest issues is the food, I believe it could be better. Resident #109 was about his food and dining preferences. Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for two of 29 residents in the survey sample, Resident #105 and Resident #42. Resident #105 was administered another resident's medications in error. Nurses failed to clarify a physician's order prior to administration of a medication to Resident #42. The findings include: 1. Resident #105 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphasia, hypertension, depression, hemiplegia/hemiparesis, muscle weakness, anemia, and complex regional pain syndrome. The minimum data set (MDS) dated [DATE] coded the resident as being moderate cognitively impaired for daily decision making with a score of 8 out of fifteen. Resident #105's clinical record was reviewed on 07/31/19 at 9:30 a.m. Resident #105's clinical record documented a nursing note dated 07/04/19 at 11:57 a.m. as follows: This am (morning) res. (resident)…

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

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure physican's orders were in place for a hand splint for Resident # 1. Findings include: Resident # 1 was admitted to the facility 4/4/19 with a readmission date of 5/28/19. Diagnoses for Resident # 1 included, but not limited to: chronic congestive heart failure, cortical blindness, spina bifida, diabetes, history of stroke, and hemiplegia/hemiparesis of left side following stroke. The most recent MDS (minimum data set) was a quarterly review dated 7/19/19. Resident # 1 was assessed as being cognitively intact with a total summary score of 13 out of 15. During the initial tour of the facility 7/30/19 beginning at 10:15 a.m., Resident # 1 was observed with a splint on his left hand. When asked about the splint, Resident # 1 stated I had a stroke and a heart attack on the operating table; I wear this now because my hand is contracted. I think it's to help straighten out my fingers. Resident # 1 was then asked how many hours per day the splint was worn. Resident # 1…

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 resident interview, the facility staff failed to implement care plan interventions for vision deficit for one of 29 residents, Resident #56; and failed to develop a care plan for a hand splint for one of 28 residents, Resident #1. Findings were: 1. Resident #56 was admitted to the facility on [DATE] with the following diagnoses, included, but not limited to: Major depressive disorder, elevated blood pressure, absolute glaucoma, legal blindness, hypokalemia and diabetes mellitus. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 06/17/2019 assessed Resident #56 as cognitively intact with a summary score of 15. On 07/30/2019 at approximately 12:15 p.m., Resident #56 was observed in her room. After knocking on the door, Resident #56 turned her head to the door and stated, Who's there? Resident #56 also stated, I'm blind .I can see your shape, but that's it. On 07/31/2019 at approximately 8:30 a.m., Resident #56 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, resident interview, and facility document review, the facility staff failed to provide nail care for one of 29 residents, Resident #56. Findings were: Resident #56 was admitted to the facility on [DATE] with the following diagnoses, included, but not limited to: Major depressive disorder, elevated blood pressure, absolute glaucoma, legal blindness, hypokalemia and diabetes mellitus. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 06/17/2019 assessed Resident #56 as cognitively intact with a summary score of 15. On 07/31/2019 at approximately 8:30 a.m., Resident #56 was observed sitting on the side of her bed eating breakfast. The thumb nail on her right hand and the pinky nail of her left hand were observed as long, dark in color and curved. All of her other nails were cut short. She was asked why those two nails were long. She stated, Nobody has cut them. She was asked why the others were short. She stated, I…

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 physician orders for three of 29 residents in the survey sample. Facilty staff failed to obtain vital signs every 4 hours after a medication error for Resident #105; failed to follow orders for medication administration for Resident #123, and failed to implement a bowel management program for Resident #76. The findings include: 1. Resident #105 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphasia, hypertension, depression, hemiplegia/hemiparesis, muscle weakness, anemia, and complex regional pain syndrome. The minimum data set (MDS) dated [DATE] coded the resident as being moderate cognitively impaired for daily decision making with a score of 8 out of fifteen. Resident #105's clinical record was reviewed on 07/31/19 at 9:30 a.m. Resident #105's clinical record documented a nursing note dated 07/04/19 at 11:57 a.m. as followed: This am (morning)…

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 follow physician's orders to float heels while in bed, for one of 29 residents in the survey sample, Resident #121. The Findings Include: Resident #121 was admitted to the facility on [DATE]. Diagnoses for Resident #121 included; Diabetes, dementia, Alzheimer's disease, and dysphagia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/10/19. Resident #121 was assessed with a score of 4 indicating severe cognitive impairment. On 7/30/19 Resident # 121's medical record was reviewed. An active physician's order dated 10/4/16 documented float heels when in bed to decrease pressure on heels. On 7/31/19 at 9:50 AM, Resident #121 was observed laying in bed. Resident #121's certified nursing assistant (CNA #3) was standing just outside Resident #121's door and was asked to observe Resident #121's heels while in bed. Resident #121's heels were observed laying against…

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 29 residents in the survey sample was free of unnecessary medications. Resident # 71 in the survey sample had a PRN (as needed) order for Ativan for longer than 14 days without a stop date. The findings were: Resident # 71 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included hyperlipidemia, Cerebral Palsy, Non-Alzheimer's dementia, seizure disorder, anxiety disorder, depression, psychotic disorder, dysphagia, cognitive communication deficit, moderate intellectual disabilities, generalized muscle weakness, tracheostomy status, and gastroesophageal reflux disease. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 6/6/19, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 02 out of 15. Resident 71 had the following order, dated 10/9/17, for Ativan solution 2…

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 label a medication accurately for one of 29 residents in the survey sample. Resident #42's medication Synthroid was labeled by the pharmacy with inaccurate dosage instructions. The findings include: Resident #42 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #42 included cerebral infarction, lymphedema, diabetes, hypothyroidism, atrial fibrillation, obesity and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #42 as cognitively intact. A medication pass observation was conducted on 7/31/19 at 7:40 a.m., with licensed practical nurse (LPN #1) administering medication to Resident #42. Among the medications administered to Resident #42 was Synthroid 50 mcg. Resident #42's clinical record documented a physician's order dated 1/7/18 for Synthroid 50 mcg each morning with instructions to give the 50 mcg tablet along with a 12.5 mcg tablet for a total…

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 ensure laboratory results were promptly reported to the physician for one of 29 residents (Resident #77). Findings include: Resident #77 was admitted to the facility on [DATE], with the most current readmission 4/17/19. Diagnoses for Resident #77 included, but were not limited to: history of a stroke, diabetes mellitus, obesity, hyponatremia, neuropathy, high blood pressure, peripheral vascular disease, above the knee amputation of the left leg and seizure disorder. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 12, indicating the resident had moderate impairment in daily decision making skills During clinical record review, the resident's nursing notes documented that on 6/10/19 (Monday) the resident had new onset of involuntary extremity jerking on the right side and the resident was administered lorazepam 0.5 mg (milligrams) as a one time…

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 were followed for medication administration. Finding include: On 07/31/19 at 7:45 AM during a medication pass and pour observation, LPN (Licensed Practical Nurse) #4 applied gloves and began preparing medications for Resident #74. LPN #4 prepared ordered medications, which included two baclofen tablets. LPN #4 took the medications to the resident with gloved hands. Resident#74 took the cup of pills and dropped one onto the bed, which then fell to the floor. The medication tablet was picked up by LPN #4 with her gloved hand. The medication was identified as baclofen. LPN #4 took the pill and the resident's water cup and threw it into the trash can. LPN #4 told the resident that she would replace the dropped medication with a new pill. LPN #4 went to the medication cart, pushed a new baclofen tablet pill out of a blister card package, touching the pill with her gloved hand and put the tablet into the medication cup and took 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.