Charlottesville Health & Rehabilitation Center

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain essential equipment in safe, operating condition the main kitchen. The findings included: 1. The facility staff failed to maintain the kitchen's walk-in freezer in operating condition. On 3/18/25 at approximately 4 p.m., during observations of the kitchen, it was noted that the freezer door was damaged and did not close completely. When the freezer door was opened, a significant amount of ice buildup was observed around the door jamb, which extended about 4 inches up the door frame. The food packages closest to the door had a buildup of frost. The gasket on the door was not attached at the bottom, about 12 inches of the gasket moved when the door was opened. On the back wall of the freezer was frozen streams of ice and the rear floor was incapsulated with ice build-up that covered the back 1/3 of the walk-in freezer floor. The ice incapsulated a milk crate that was sitting in the floor. On 3/18/25 at 4:05 p.m., an interview was conducted with the cook (other employee #4-…

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

Based on observation, resident interviews, staff interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to provide meals in accordance with resident preference for 2 residents (Resident #2 - R2 and Resident #10 - R10) out of a survey sample of 8 residents. The findings included: 1. The facility staff failed to serve R2's choice of an entree and a lidded cup with the lunch time meal. On 3/18/25 at 12:15 p.m. an observation was made of R2's lunch meal. R2's meal ticket read that a baked pork chop was the entree requested, but it was observed that she received the flat baked ham and no lidded cup for R2's beverage was observed on her meal tray. On 3/18/25 at 12:30 p.m. an interview was conducted with R2. R2 said, I usually get a pork chop and not ham. R2 stated that she liked a lidded cup but was never given a lid on the cup with meals. On 3/18/25 at 2:00 p.m. a review of the clinical record was conducted. R2's care plan was reviewed and documented that R2 preferred lidded cups with meals. On 3/18/25 at 4:00 p.m. a review of resident council…

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 notify the responsible party of a change in condition for one of four residents in the survey sample, (Residents #3). Resident #3's (R3) responsible party was not notified of a fall with injury. This was a closed record review. The findings include: According to the clinical record, diagnoses for R3 included; Encephalopathy, fractured right pubis, dementia, pneumonia, and aseptic necrosis of the left femur. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 11/22/23. R3 was assessed with a cognitive score of 3 out of 15, indicating severely cognitively impaired. On 12/3/24 R3's clinical record was reviewed regarding a fall incident occurring on 11/12/23. The note indicated R3 got up out of wheelchair with right leg still crossed behind left foot. Before the nurse could catch R3, R3 landed on knees and obtained a skin tear to the left elbow. Review of the SBAR (Situation Background Appearance Review) notification section; it 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 facility record review, the facility staff failed to have a surety bond to assure the security of all personal funds of residents deposited with the facility, which affected 72 residents who had funds deposited with the facility. The findings included: On 7/10/24 the facility staff provided a surety bond which was in the amount of $165,000. On 7/10/24, a review of the resident trust accounts revealed that there were 72 residents with funds deposited at the facility. The total balance was $180,783.50. The surety bond did not have sufficient coverage to cover the funds deposited with the facility. On 7/10/24, during an end of day meeting, the facility administrator was made aware of the above findings. Following the end of day meeting, the administrator came to the conference room and a list of residents that she said the business office said they needed to close the accounts for. The surveyor then went to the business office manager's (BOM) office. The BOM said she had just started at the facility and had identified several accounts that need to be…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, staff interviews, and facility documentation review, the facility staff failed to maintain sufficient nurse staffing to assure resident safety and highest practicable well-being of each resident, to meet their daily needs in accordance with the facility assessment, for 2 of 2 nursing units. The findings included: On 7/8/24, during initial tour of the facility and interviews with the residents, numerous residents expressed concerns about the facility staffing. The residents reported having to wait long periods of time, that they described as over an hour, for call bell responses. On 7/8/24 at 2:20 p.m., the Ombudsman met with the survey team. The Ombudsman reported, staffing is horrible. I think it is dangerous. Especially on weekends, people feel like they can just call out, it is like a revolving door. I worry, they don't have an intercom system, if they put their call light on, it is on for an hour. If someone has fallen, this is dangerous. On 7/8/24 at 3:07 p.m., a group meeting…

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 documentation review, the facility staff failed to store, prepare, and serve food accordance with professional standards for food safety in the main kitchen, which has the potential to affect multiple residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to store food at an appropriate temperature in the walk-in refrigerator. On 7/8/24 at 11 a.m., a tour of the kitchen was conducted with a dietary aide and cook (other employee #11- OE11), in the absence of the dietary manager. On 7/8/24 at 11 a.m., upon entry into the walk-in cooler, it was noted that the temperature did not feel cool enough to ensure food safety. The internal thermometer located within the fridge was observed to be reading 55 degrees Fahrenheit. OE11 was asked about the cooler, and he reported, It feels cold enough to me. When asked about the temperature readings and records, OE11 said, maintenance checks that, and said the logs should be hanging on the wall. There were no temperature logs available for any of the food storage…

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 interviews, facility documentation review and clinical record review, the facility staff failed to assess and determine if a Resident was safe to self-administer medications that were at the bedside, for one Resident (Resident #28) in a survey sample of 26 Residents. The findings included: For Resident #28 (R28), who had multiple medications stored on the over bed table and bedside table, in their room, the facility staff failed to assess if the resident was safe to self-administer medications. On 7/8/24 at 12:42 p.m., observations were conducted in R28's room and an interview with R28 was conducted. During the interview, it was observed that R28 had prescription nasal spray which was Ipratropium Bromide and had a pharmacy label with an RX # and date of 4/16/24. Also at the bedside was sterile eye drops and a toothache cream on the over bed table which was positioned at the bedside. When asked, R28 said she is supposed to use the nasal spray 3 times a day, but most days only uses it twice. R28 also said, she uses the eye drops…

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 family interview, staff interview, facility document review and clinical record review, the facility staff failed to provide advance written notice of a room change for one of twenty-six residents in the survey sample (Resident #77). The findings include: Resident #77 (R77) nor R77's responsible party were provided a written notice prior to a room change. R77 was admitted to the facility with diagnoses that included adult failure to thrive, deep vein thrombosis, insomnia, severe protein-calorie malnutrition, major depressive disorder, cancer, and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R77 with moderately impaired cognitive skills. On 7/8/24 at 2:30 p.m., R77's family member (other #7) was interviewed. R77's family member stated the facility moved the resident to a different room on 7/1/24 and that there had been no advance notice of the room change. The family member stated she was not aware of any written notice provided about the room change. R77's clinical…

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 facility staff interview, clinical record review and facility documentation review, the facility staff failed to obtain and incorporate the recommendations from a level II PASARR (preadmission screening and resident review) into the Resident's assessment and care plan for one Resident (Resident #46) in a survey sample of 26 Residents. The findings included: For Resident #46 (R46), who had a level II PASARR, the facility staff were unaware until requested by the survey team, that the Resident had a level II screening and failed to incorporate the recommendations into the Resident's assessment and care planning. On 7/8/24, a clinical record review was conducted of R46's electronic health record. The census tab of the clinical record revealed R46 was initially admitted to the facility on [DATE]. R46 did have several hospitalizations and the most recent readmission was on 10/7/23. R46's diagnosis included but were not limited to hemiplegia and hemiparesis following other cerebrovascular disease affecting…

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 ensure that residents receive devices to prevent accidents for one resident (Resident #28- R28), in a survey sample of 26 residents. The findings included, For R28, who had a recent fall, the facility staff failed to ensure the resident had fall interventions in place to prevent further accidents. On 07/08/24 at 1:19 p.m., an interview was conducted with R28. R28 reported that she has had several falls while at the facility. When asked what interventions were put in place to prevent future falls, the resident said she didn't know. Observations revealed no fall mat within the room. On 7/8/24, a clinical record review was conducted of R28's chart. According to the Post Fall Investigation document in the assessment tab of the chart, it indicated that R28's most recent fall was on 6/16/24. There were also Post Fall Investigation assessments completed on 12/15/23, 10/26/23, 9/19/23, 9/18/23, and 9/14/23. According to the care plan R28 had a focus area initiated on…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, facility document review, and clinical record review, the facility staff failed to ensure that each resident received the necessary respiratory care, services, and failed to appropriately store respiratory equipment, in accordance with professional standards of practice for two residents (Resident #84 and Resident #28) in a survey sample of 26 residents. The findings included: 1. The facility staff failed to obtain a physician order prior to administering oxygen to Resident #84 (R84) and failed to label the oxygen tubing with the date. According to the clinical record, R84 was admitted to the facility on [DATE] and has diagnoses that include but are not limited to congestive heart failure, pressure ulcer of sacral region - Stage 3, pressure ulcer of the right buttocks - Stage 3, and cutaneous abscess of back. R84's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 6/18/24 coded R84 with no cognitive impairment with daily decision making.…

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 ensure prn (as needed) orders for psychotropic medication was limited to 14 days, affecting 1 resident (Resident #82- R82), in a survey sample of 26 residents. The findings included: For R82, the facility staff failed to ensure that a prn order for lorazepam was limited to 14 days. On 7/8/24 at 2:33 p.m., R82 was visited in her room. R82 was able to communicate with the surveyor but confusion was evident. R82 appeared calm and not anxious during the interview. On 7/8/24, a clinical record review was conducted of R82's chart. This review included a review of the physician orders, progress notes and medication administration records (MARs). It was noted that R82 had a physician order dated 5/1/24, that read, Lorazepam oral concentrate 2 mg/ml (Lorazepam) give 1 ml by mouth every 1 hours as needed of end-of-life anxiety. The order had no end date and remained an active and current order. According to the MAR, R82 received the lorazepam on 5/3/24, 6/30/24,…

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.

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to provide meal substitutions in accordance with resident preferences for one resident (Resident #32- R32), in a survey sample of 26 residents. The findings included: On 7/8/24 at approximately 12:30 p.m., R32 was observed being served her lunch meal in the dining room by a dietary aide, (Other Employee #9-OE9). R32 asked OE9 for a grilled cheese sandwich and OE9 was heard to say to the resident, That's what you ordered, and walked away. A few minutes later OE9 served another resident their plate and as OE9 walked by R32, R32 again asked for a grilled cheese sandwich. OE9 told R32 again, That's what you ordered, it's not pork. When the surveyor then walked over to R32, OE9 said to the the surveyor, That's what she ordered. R32 then said to the surveyor, I don't want that. I want a grilled cheese sandwich. On 7/8/24 at 12:45 p.m., R32 was observed in the dining room, eating a cold turkey and cheese sandwich. When asked about the sandwich, R32 said, It wasn't what 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.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a therapeutic diet in accordance with physician orders for one resident (Resident #82- R82) in a survey sample of 26 residents. The findings included: For R82, who had a physician order for nectar thickened liquids (NTL), the facility staff failed to provide thickened liquids. On 7/8/24 at approximately 12:30 p.m., observations were conducted of R82 during the lunch meal. R82 was served a beverage with her lunch meal that was an amber color, which appeared to be apple juice. There was ice in the cup, and it was noted to be a thin consistency. R82 also had a water pitcher that when picked up you could tell there was a liquid with ice that was able to be swirled around in the pitcher. According to the meal ticket that was on the lunch tray, R82 was noted to have been on NTL. On 7/8/24 at 12:47 p.m., LPN #6 accompanied the surveyor to the room of R82. LPN #6 confirmed that the resident was served thin liquids, and she opened the water pitcher 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 and clinical record review, the facility staff failed to provide a complete and accurate clinical record for one of twenty-six residents in the survey sample (Resident #77). The findings include: Resident #77's clinical record did not include recent hospice notes/documentation. Resident #77 (R77) was admitted to the facility with diagnoses that included adult failure to thrive, deep vein thrombosis, insomnia, severe protein-calorie malnutrition, major depressive disorder, cancer, and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R77 with moderately impaired cognitive skills. R77's clinical record documented the resident had been receiving hospice care/services since 1/19/24. R77's clinical record documented no hospice notes or record of provided hospice services since mid-April 2024. On 7/10/24 at 8:35 a.m., the director of nursing (DON) was interviewed about R77's hospice notes. The DON stated hospice was required to provide notes after visits 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 observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control practices for one of 26 residents. The findings include: For Resident #84 (R84), who was on enhanced barrier precautions, the facility staff failed to wear PPE (personal protective equipment) while providing direct care. According to the clinical record, R84 was admitted to the facility on [DATE]. Diagnoses for R84 included but are not limited to pressure ulcer of sacral region - Stage 3, pressure ulcer of the right buttocks - Stage 3, and cutaneous abscess of back. R84's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 6/18/24 coded R84 with no cognitive impairment with daily decision making. On 7/9/24 at 8:15 a.m. a tour of unit one was conducted. During the tour, R84 observed residing in the A bed, which was closest to the door. The room had a sign outside the room, above the resident's name that indicated enhanced barrier precautions…

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 documentation review the facility staff failed to ensure CNA's (certified nursing assistant) received 12 hours of in-service training per year for one CNA (CNA #8), in a survey sample of two CNA's reviewed. The findings included: For CNA #8, the facility staff failed to ensure that a minimum of 12 hours of in-service training per year was provided. On 7/9/24, a sample of two CNA's was selected for review of annual education. CNA #8, who was hired 8/30/22, was selected for review. The facility administrator was asked to provide all of CNA #8's training from 8/30/22-8/30/23, for review. Review of the Relias Official Transcript provided, revealed CNA #8 only had 4.75 hours of training during the timeframe reviewed, none of which included dementia management or care of the cognitively impaired. Also provided was the transcript for CNA #8 for 2024, which included 1.5 hours of training, which consisted of: HIPAA (privacy and confidentiality), Infection Control and Bloodborne Pathogens. According to the facility assessment, in part 2 titled, Services…

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, facility document review, and clinical record review, the facility staff failed to follow posted menus for six of ten residents in the survey sample (Residents #1, #2, #3, #5, #6 and #10). The findings include: Residents #1, #2, #3, #5, #6 and #10 were not served food items as listed on the posted menu and/or meal tickets. On 4/8/24 at 2:20 p.m., the resident council president (Resident #5) was interviewed about meals/food service in the facility. The council president stated that foods served rarely matched the posted menus or meal tickets. The council president stated concerns with food had been discussed in council meetings for several months and dietary staff reported they were working to improve. The posted breakfast menu for 4/9/24 included scrambled eggs, bran muffin, oatmeal, whole milk, orange juice with alternates listed as hard-boiled eggs, wheat toast, and assorted cold cereals in addition to coffee or hot tea. On 4/9/24 at 8:30 a.m., meals served to Residents #1, #2, #3, #5, #6 and #10 were observed and compared…

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

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to serve food at an appetizing temperature on one of two units (unit 1). The findings include: On 4/8/24 at 2:50 p.m., the resident council president, Resident #5 (R5), was interviewed about food/meals in the facility. R5 stated meals served to residents in rooms were usually cold. R5 stated issues with cold food and missing food items had been discussed multiple times in the council meetings and dietary staff reported they were working to improve. With the council president's permission, the resident council meeting minutes were reviewed from January, February and March (2024). Minutes documented residents expressed concerns that the overall appearance/taste of food needed improvement and foods were not served hot. The posted menu for 4/9/24 lunch included spaghetti with meatballs, Italian mixed vegetables, garlic bread, chocolate chip cookie, whole milk, coffee and tea. The alternate menu included grilled marinated chicken breast, whole kernel corn, mashed potatoes,…

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 notify the responsible party of changes in medications for one of ten residents in the survey sample (Resident #7). The findings include: Resident #7 (R7) had multiple medication changes with no notification to R7's family/responsible party. Resident #7 was admitted to the facility with diagnoses that included hip fracture, Alzheimer's, traumatic brain dysfunction, hypothyroidism, anemia, osteoporosis, anxiety, depression, seizures, and protein-calorie malnutrition. The minimum data set (MDS - assessment tool) dated 5/23/23 assessed R7 with severely impaired cognitive skills for daily decision making. R7's clinical record documented physician ordered medication and/or medication dose changes as follows: 5/18/23 Celexa increased from 10 mg (milligrams) per day to 20 mg per day for treatment of depression. 5/26/23 Celexa was discontinued and the antidepressant Zoloft 75 mg per day was started. 6/03/23 Antibiotic cephalexin 500 mg every 12 hours for 7 days for treatment of a leg abrasion with cellulitis.…

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 resident centered care plan for one of 4 resident's. Resident #1 (R1) did not have resident specific interventions for nutrition, vision, activities of daily living (ADL's), and bowel incontinence. The Findings Include: Diagnoses for R1 included; irritable bowel syndrome (IBS), lactose intolerant, chronic diarrhea, and retinopathy with macular edema. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 9/14/23. R1 was assessed with a cognitive score of 15 out of 15, indicating intact cognition. During an interview on 12/4/23 at 11:20 AM, R1 verbalized that he could only see the outline of a person and shapes, but was able to get to the bathroom by counting steps and feeling the wall. R1 went on to say that he is lactose intolerant and that foods cooked with milk upsets his stomach, requiring the immediate use of the bathroom. R1 verbalized that if the urge…

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 failed to provide meals to accommodate food allergies/intolerance for one of 4 resident's. Resident #1 (R1) was served food that exacerbated his medical condition. The Findings Include: Diagnoses for R1 included irritable bowel syndrome (IBS), lactose intolerant, chronic diarrhea, and retinopathy with macular edema. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 9/14/23, which assessed R1 with a cognitive score of 15 out of 15, indicating intact cognition. During an interview on 12/4/23 at 11:20 AM, R1 verbalized that he is lactose intolerant but is served food containing milk, which upsets his stomach and results in needing to use the bathroom right away. R1 verbalized that the aides will serve his food but don't say what the meal is or where the items are on the tray. R1 said that because of the inability to see, he eats what he is served, but that if he knew what was on the tray, then he would be able to make a choice if the food would…

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, clinical record review, and staff interview the facility staff failed to follow physicians orders for the administration of the correct formulation of a multi-vitamin for one of 22 residents in the survey sample, Resident # 9. Resident # 9 was ordered Men's Daily Health Formula and instead was administered a regular multi-vitamin for a period of five months. Findings include: Resident # 9 was admitted to the facility 6/1/21. Diagnoses for Resident # 9 included, but were not limited to: Malignant neoplasm of the rectum and pancreas, diabetes, depression, congestive heart failure, and peripheral vascular disease. The most recent MDS (minimum data set) was a quarterly assessment dated [DATE] with the resident being scored with moderate impairment in cognition with a score of 11 out of 15. On 11/8/21 a medication pass and pour observation was conducted with LPN (licensed practical nurse) # 1 beginning at 7:55 a.m. Medications administered to Resident # 9 were then reconciled against physician…

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

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practice during a medication pass observation on one of two units. Thirteen oral medications were touched by the nurse's bare hands/fingers prior to administering them to residents during a medication pass on unit two. The findings include: On 11/8/21 at 7:37 a.m., a medication pass observation was conducted on unit two with registered nurse (RN) # 1 administering oral medications to Resident #23. During this observation, RN #1 touched and/or handled each of seven medication tablets with her bare hands and/or fingers prior to administering them to the resident. RN #1 popped six of the seven tablets from the medication supply cards into her bare hand prior to placing them in a cup. RN #1 reached her index finger into the supply bottle and retrieved an aspirin tablet before placing in the medication cup. Tablet medications touched then administered to Resident #23 included vitamin D, ferrous sulfate, aspirin, Fenofibrate, lisinopril,…

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 develop a baseline care plan for one of 22 in the survey sample, Resident #289. Resident #289's baseline care plan failed to include a problems/focus area, goals and interventions for the anticoagulant medication, Apixaban. The findings include: Resident #289 was admitted to the facility on [DATE] with diagnoses that included pulmonary embolism, history of COVID 19, respiratory failure with hypoxia, hypercholesteromia, hypertension, osteoarthritis, and long term use of anticoagulants. The nursing admission assessment dated [DATE] assessed Resident #289 as alert and oriented to person, place, time and situation, having intact cognition and with the ability to express ideas/wants. On 11/08/2021 at 2:13 p.m., Resident #289 was interviewed regarding the quality of care since admission to the facility. Resident #289 stated she was admitted after a hospital stay due to testing positive for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of 22 in the survey sample, Resident #60. Resident #60's comprehensive care plan did not include a problem/focus area with goals and interventions for the use the anticoagulant medication, Heparin Sodium Solution. The findings include: Resident #60 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hyperlipidemia, depression, acute embolism and thrombosis of left popliteal vein, hypothyroidism, osteoarthritis, difficulty walking and orthopedic aftercare. The nursing admission assessment dated [DATE] assessed Resident #60 as alert and oriented to person, place and situation, having intact cognition and the ability to express wants/ideas. On 11/09/2021, Resident #60's clinical record was reviewed. Observed on the order summary report was the following: Heparin Sodium (Porcine) [an anticoagulant] Solution 5000 Unit/ML Inject 1 ml…

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 perform a pressure ulcer dressing change in a manner to prevent infection for one of twenty-two residents in the survey sample, Resident #33. A nurse failed to perform hand hygiene between glove changes during dressing changes to Resident #33's pressure ulcers. The findings include: Resident #33 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #33 included atherosclerotic heart disease, glaucoma, peripheral vascular disease, benign prostatic hypertrophy, atrial fibrillation, chronic kidney disease, anemia, gastroesophageal reflux disease, depression, dysphagia, urinary tract infection and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed Resident #33 with moderately impaired cognitive skills. Resident #33's clinical record documented the resident had three stage 3 pressure ulcers on his buttocks. A consultant wound…

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 implement use of safety devices for one of twenty-two residents in the survey sample, Resident #36. Resident #36 was observed in a wheelchair without anti-rollback devices as required in his plan of care for fall/injury prevention. The findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction with right side hemiplegia, atherosclerotic heart disease, hypertension, vascular dementia, osteoarthritis, anxiety disorder, depression, gastroesophageal reflux disease, chronic kidney disease, mood disorder and urinary tract infection. The minimum data set (MDS) dated [DATE] assessed Resident #36 with short and long-term memory loss and moderately impaired cognitive skills. On 11/8/21 at 9:09 a.m., Resident #36 was observed seated in his wheelchair, self-propelling about in his room. No anti-rollback devices were installed or in use on the wheelchair. Resident #36 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 staff interview and clinical record review, the facility staff failed to ensure two of 23 residents were free from unnecessary medications. Residents #13 and #73 had physician orders for as needed (prn) psychotropic medications in place for greater than 14 days. These as needed prescriptions were continued beyond the 14-day limit without a specified duration. 1. Resident #13 had a physician's order for prn (as needed) Lorazepam in place greater than 14 days. This prescription was continued without a specified duration. 2. Resident #73 was prescribed Ativan (psychotropic medication) on an as needed basis for longer that 14 days without thorough justification. The findings include: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia, intracranial abscess, gastroesophageal reflux disease, dysphagia, heart failure, kidney failure, depression, anxiety disorder and osteoarthritis. The minimum data set (MDS) dated [DATE] assessed Resident #13 as cognitively intact.…

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

Based on clinical record review and staff interview, the facility failed for one of 23 residents in the survey sample (Resident # 145), to ensure a PASARR, used to screen for a mental disorder or intellectual disability, was completed prior to the resident's admission to the facility. Resident # 145 was admitted to the facility without a PASARR, which prevented the facility from knowing if the resident required specialized treatment or services to address a mental disorder or intellectual disability. The findings were: Resident # 145 was admitted to the facility from his home on 2/5/19 with diagnoses that included major depressive disorder, bipolar disorder, hypertension, hypothyroidism, hyperlipidemia, benign prostatic hyperplasia, Vitamin D deficiency, and chronic kidney disease. At the time of the survey, the resident's admission Minimum Data Set was not yet completed. On the date of admission, 2/5/19, the resident received the following medication order: Prozac Capsule 40 mg. (milligrams). Give 1 capsule by mouth one time a day related to Major Depressive Disorder. (NOTE: Prozac…

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 develop a baseline care plan for one of 23 residents, Resident #344. Resident #344's baseline care plan failed to include any problems, goals, and/or interventions for ADL assistance (activities of daily living) and dietary instructions. The findings include: Resident #344 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, change in bowel habit, vitamin deficiency, unspecified joint pain, seizures, constipation, acute embolism and thrombosis of veins - lower extremities, and atrial fibrillation. The nursing admission assessment dated [DATE] assessed Resident #344 as alert and oriented to person. This assessment documented the resident as incontinent of bowels and bladder, total dependence with one person physical assist for toileting. The assessment documented the resident requiring extensive assistance, with one personal physical assist for eating. Resident #344'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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed for two of 23 residents in the survey sample (Resident # 23 and 46), to develop a plan of care that encompassed the resident's total care needs. 1. For Resident # 46, the facility failed to develop a plan of care that addressed the resident's whirlpool treatments for localized edema, and for the refusal of the treatments; and, failed to develop a plan of care to address the resident's use of psychotropic medications. 2. Resident #23 had no care plan developed regarding tooth pain and difficulty chewing due to broken teeth. The findings were: 1.a. Resident # 46 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included congestive heart failure, hypertension, diabetes mellitus, hyperlipidemia, Non-Alzheimer's dementia, anxiety disorder, depression, chronic obstructive pulmonary disease, difficulty walking, chronic kidney disease, generalized muscle weakness, urge incontinence, dermatitis,…

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 review and revise the comprehensive care plan for one of 23, Resident #65. Resident #65's care plan was not revised to reflect interventions for skin integrity. The Findings Include: Resident #65 was admitted to the facility on [DATE]. Diagnoses for Resident #65 included: Subdural hemorrhage, hemiplegia affecting the right side, muscle weakness, and schizoaffective disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/25/19. Resident #65 had a cognitive score of 15, indicating cognitively intact. On 02/12/19 at 1:48 PM, Resident #65 was interviewed. Resident #65 verbalized he prefered to spend most the day in bed but would like to get out of bed for short periods of time during the day. During the interview Resident #65 was observed laying in bed without any heel protectors. On 2/13/19 Resident #65's medical record was reviewed. A physician order…

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, family interview, staff interview and clinical record review, the facility staff failed to assess and implement interventions to maintain and/or improve the ability to carry out activities of daily living (ADLs) for one of 23 residents in the survey sample. Resident #196, with no restricted activities, remained in bed for one week following a re-admission to the facility after a hospitalization. Staff reported they were waiting for a therapy assessment before getting the resident out of bed. There was no assessment by any discipline during the week following the re-admission regarding the resident's transfer and mobility needs. The findings include: Resident #196 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #196 included chronic obstructive pulmonary disease, heart failure, respiratory failure, obesity, urinary retention and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident#196 as cognitively intact. This…

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

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 follow physician orders for one of 23 residents in the survey sample. A dose of the medication Neurontin was not administered to Resident #82 as prescribed by the physician. The findings include: Resident #82 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #82 included urinary tract infection, history of sepsis, pyelonephritis, chronic kidney disease, dysphagia, restless leg syndrome, gastroesophageal reflux disease and anxiety. The minimum data set (MDS) dated [DATE] assessed Resident #82 as cognitively intact. Resident #82 was interviewed on 2/13/19 at 8:25 a.m. about quality of life/care in the facility. Resident #82 stated that at times she got her medications late. The resident stated as recent as last week she missed a dose of Neurontin because the nurse did not administer it on time. Resident #82 stated she was due a dose of Neurontin each night at midnight.…

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 follow physician's orders for treatment and care of skin integrity for two of 23 resident's, Resident #65 and Resident #196. 1. Resident #65 did not have physician ordered heel protectors (prevlon boots) on while in bed. 2. Resident #196 developed a stage 2 pressure ulcer on her left upper buttock after remaining in bed for one week following a re-admission and without application of a specialized mattress as required in her plan of care for pressure ulcer prevention. The Findings Include: 1. Resident #65 was admitted to the the facility on 12/28/18. Diagnoses for Resident #65 included: Subdural hemorrhage, hemiplegia affecting the right side, muscle weakness, and schizoaffective disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (Assessment Reference Date) of 1/25/19. Resident #65 had a cognitive score of 15, indicating cognitively intact. On 02/12/19 at 1:48…

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 safety interventions were in place to help prevent accidents and injury for one of 23 residents , Resident #16. Resident #16 was not moved closer to the nurses station as indicated in the Resident's care plan intervention for falls. The Findings Include: Resident #16 was admitted to the the facility on 11/12/18. Diagnoses for Resident #16 included: COPD, Major depression, , anxiety, hypoxemia, bilateral knee replacements. The most current MDS (minimum data set) was an admission assessment with an ARD (Assessment Reference Date) of 11/19/18. Resident #16 had a cognitive score of 14 indicating cognitively intact. On 02/13/19 at 9:01 AM, an interview was conducted with Resident #16. During the interview Resident #16 mentioned she has had a couple of falls recently but without injuries. Resident #16 verbalized a walker was used for mobilization and that she gets up without assistance. Resident #16 was also observed with a wandergaurd in place. On 2/13/19 Resident #16's care plan was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview and clinical record review, the facility staff failed to provide dental services for two of 23 residents in the survey sample. Resident #23 was not provided dental services regarding assessed broken, painful teeth that caused chewing difficulty. Resident #82 was not provided services to replace two dislodged dental crowns. The findings include: 1. Resident #23 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #23 included epilepsy, cerebrovascular disease, cervical disc disorder, insomnia, neurogenic bladder, high blood pressure, hemiplegia, depression, heart failure and atrial fibrillation. The minimum data set (MDS) dated [DATE] assessed Resident #23 as cognitively intact. On 2/13/19 at 1:08 p.m., Resident #23 stated he had been asking to see a dentist for about 3 months because of some broken teeth that were making it difficult to chew. Resident #23 stated his teeth hurt at times and they were now cutting his meats into…

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.