The Laurels Of Charlottesville

Based on observation, resident and staff interviews, the facility staff failed to uphold resident rights and knock before entering residents rooms on one of three resident care units (200 unit).The findings included: 1. On the 200 unit, the nursing staff were observed to enter residents' rooms without knocking and requesting permission to enter.On 7/22/2025 at 8:37 a.m., a certified nursing assistant (CAN #5) was observed to enter rooms 201, 203 and 206 without knocking or requesting permission to enter, before entering the residents' rooms. When questioned CNA #5 aid, Yes I should knock when I enter a resident's room. When the observations were discussed and she was asked why she had not knocked, CNA #5 said, No reason that I didn't knock, just busy I guess, I usually do knock on the doors. On 7/22/25 at 3:00 p.m., during a resident council meeting, the residents reported that some staff knock before entering and some do not. 2. The facility staff failed to knock prior to entering Resident #22's (R22) room.On 7/22/25 at 3:39 p.m., while the surveyor was conducting an interview with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide written notice for a room change prior to the move, affecting two residents, Resident #17 (R17) and Resident #38 (R38) out of a survey sample of 33 residents. The findings included: R17 had to change rooms from one unit to another unit and was not notified in writing by facility staff prior to the room change. On 7/22/25 at 8:44 a.m., an interview was conducted with R17. She had a concern about changing rooms from one unit to another unit to remain long term care (LTC) and was not notified by the staff at the facility prior to the room change. On 07/24/2025 at 8:20 a.m., an interview was conducted with the social service director. She stated that the process for a room change for a resident was they had to be notified in writing about the room change prior to changing rooms. She stated she was not employed here when R17's room change occurred but R17 is her own responsible…

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 and facility documentation the facility staff failed to provide a private area without staff interference for the Resident council meeting.The findings included:On 7/22/25 at 3:00 p.m., a resident council meeting was held in the dining room area. A sign was posted outside the door that it was a resident council meeting being held, dietary staff were asked to keep the kitchen doors closed and staff were asked not to enter the dining room until the resident council meeting was completed. During the meeting it was observed that three staff members entered the dining room and stood in the back of the dining room area talking with staff in the kitchen. When the staff entered, it was observed that the meeting was paused until the staff exited the room.On 7/22/25 at 3:30 p.m., an interview with Resident #82 (R82) was conducted. Identified as the resident council president, R82 said, When we hold the meetings in the dining room area for more space, staff comes in and out as they want.On 7/23/25 at 4:00 p.m., a review of facility documentation 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 resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to protect the resident's right to be free from verbal abuse by staff for one resident (Resident #43- R43) in a survey sample of 33 residents. The findings included: On 7/22/2025 at 2:06 p.m., during an interview with R43, he reported that a staff member, he identified as a certified nursing assistant (CNA #7), came in one morning to get me up and she cussed me, I told her to not be cussing me, I don't cuss at y'all. She left and I rang the bell; I needed help pulling cover up. She came in and said, What the hell do you want now. I told her I was going to tell on her. R43 stated that he had talked to the administrator, and said, two or three of them talked to me about it and I talked to the police. She never took care of me again. She had done it before, one morning she was turning me over and my head hit the railing, I should have reported that but didn't. I thought she may have had a rough night and may have been tired. R43 also reported that the residents…

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 complete an accurate minimum data set (MDS) for one of thirty-three residents in the survey sample (Resident #132)The findings include:Resident #132 (R132) was admitted to the facility with diagnoses that included cerebrovascular accident (stroke), hemiplegia, atrial fibrillation, aphasia, cognitive communication deficit, diabetes, dysphagia with gastrostomy, dementia, hypertension, and pressure ulcer. The minimum data set (MDS) dated [DATE] assessed R132 with severely impaired cognitive skills. R132's clinical record documented an admission assessment dated [DATE] listing the resident had a stage 2 pressure ulcer on the sacrum. R132's clinical record documented physician orders entered on 2/17/24 for treatment of a sacral pressure ulcer with normal saline, medi-honey and foam dressing daily. R132's treatment administration records documented daily wound care to the sacral pressure ulcer as ordered. Section M0210 of R132'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 resident interview, staff interview, and clinical record review, the facility staff failed to develop a baseline care plan within 48 hours of admission for one resident (Resident #31-R31) in a survey sample of thirty-three residents.The findings included:For R31, the facility staff failed to develop a baseline care plan within 48 hours of admission that included instructions needed to provide resident-centered care. On 7/21/25, R31 was interviewed in her room. R31 reported she had come in recently from the hospital. On 7/23/25, a clinical record review was conducted of R31's electronic health records. The following was noted:R31 was admitted to the facility on [DATE]. R31's diagnosis included, but were not limited to: acute on chronic diastolic heart failure, muscle weakness, paroxysmal atrial fibrillation, chronic kidney disease- stage 3A, acute kidney failure, and osteoarthritis of knee. According to R31's care plan, each of the focus areas and interventions were dated 7/21/25, which was outside 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 and staff interviews, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nurse practice for three residents (Resident #22-R22, Resident #35-R35, and Resident #132-R132) in a survey sample of thirty-three residents. The findings included: 1. For R22, the facility staff failed to administer medications timely, within the professional standard of one hour of scheduled time, which had the potential to affect the next scheduled dose and affect level of medication within the resident’s system at a given time. On 7/22/25 at 8:20 a.m., during an interview with R22, she verbalized concern about the administration of her insulin. R22 said frequently in the morning they do not give her morning insulin until 10:30-11 a.m., and about a week ago the nurse had to not administer the afternoon dose of insulin because she had just given the morning dose. R22 said, “I think the insulin is important and you can’t just put one on top…

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, resident interviews, staff interviews, clinical record and facility documentation the facility staff failed to provide activity of daily living (ADL) assistance for three residents Resident #131 (R131), Resident #89 (R89) and Resident #35 (R35) out of a survey sample of 33 residents.The findings included: R131 was not shaved by the facility staff during his stay. R131 was no longer a resident at the facility so was unable to be interviewed. On 7/23/25 at 2:55 p.m., an interview was conducted with a certified nursing assistant, CNA#3 (CNA3). CNA3 stated that some aides were scared to shave R131. She stated she may have shaved him for an aide while he was here at the facility. CNA3 stated that she shaved him on the day of his discharge. CNA3 stated he had a lot of hair on his face and needed to be shaved. On 7/23/25 at 3:30 p.m., a clinical record review was conducted. R131's care plan was that he needed assistance with all self-care. The minimum data set (MDS) dated [DATE] coded that R131…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to administer oxygen at the physician ordered rate for one resident (Resident #35-R25) and failed to store respiratory equipment in a manner to prevent contamination for one resident (Resident #22-R22) in a survey sample of thirty-three residents. The findings included:1. For Resident #35, the facility staff failed to administer oxygen at the physician ordered rate of 2 liters.On 7/21/25 at 3:23 p.m., during an interview with R35, it was observed that an oxygen concentrator at the bedside was running, and the cannula was on the floor. When asked, R35 reported she wears the oxygen daily but was unsure at what rate/volume it was to be at. The concentrator was observed to be set just above 3 liters. On 7/22/25, a clinical record review was conducted. This review revealed that R35 had an order dated 5/28/25, that remained an active order and read, Oxygen: Oxygen at 2 liters…

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 and staff interviews, clinical record review, and facility documentation review, the facility staff failed to serve meals in accordance with resident preference for one resident (Resident #22-R22) in a survey sample of thirty-three residents. The findings included:For Resident #22 (R22), the facility staff failed to provide double meat portions as requested by the resident. On 7/22/2025 at 8:28 a.m., during an interview with R22, the resident had multiple complaints of the food and reported, .On Tuesdays they give you a menu to select menu choices for the next week, but it is pointless, they always say they are out of things. They don't pay any attention to what they are doing. On 7/23/2025 at 8:27 a.m., R22 was observed in bed and was served her breakfast. The resident received a small portion of eggs, two slices of bacon, and a cinnamon roll. The resident reported that all her food was cold. According to the resident's meal ticket it read, special diets: Double Meat Portions, Double Vegetables. Handwritten on the ticket was, Egg, 2x Bacon, Cinnamon…

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, staff interview, clinical record review and facility documentation review the facility staff failed to provide a therapeutic diet per physician orders.The findings included:Resident #59 (R59) was not served fortified foods at the lunchtime meal.On 7/21/25 at 12:00 p.m. an observation of the lunchtime meal was made by the residents in the dining room. During the meal it was observed that R59 was served a peanut butter and jelly sandwich, piece of chocolate cake and tea to drink. R59's meal ticket was read, and she should have had fortified foods with her meal. On 7/22/25 at 12:15 p.m. a second observation of R59's lunchtime meal was conducted. R59 had a peanut butter and jelly sandwich, apple crisp and juice to drink. R59 was not served any fortified food with her meal. During the observation of the kitchen serving the lunchtime meal mashed potatoes and ice cream were available to be served as the fortified foods. On 7/22/25 at 12:25 p.m. an interview was conducted with the dietary manager, and she stated fortified foods were foods like ice cream, mashed…

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 ensure a complete and accurate record for one of thirty-three residents, Resident #134.The findings Include:The facility did not document wound care on the Treatment Administration Record (TAR) for Resident #134 (R134).R134 was admitted to the facility with diagnoses that included cellulitis, right toes amputation, congestive heart failure, MRSA, and diabetes. The most recent minimum data set (MDS) was a 5-day assessment dated [DATE], R134 was assessed as being conatively intact.Review of R134's clinical record indicated an order dated 3/12/25 to complete wound care and dressing change to R134's root foot every day and evening shift starting on 3/13/25.Review of R134's TAR indicated on 3/16/25 day shift and 3/17/25 evening shift was not signed off to indicate the dressing change was completed. On 7/22/25 at 1:40 p.m. the unit manager (license practical nurse, LPN #1) where R134 resided while at the facility, was interviewed. LPN #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.

Based on observations, staff interview, clinical record review and facility documentation review the facility staff failed to implement their infection prevention and control program for one resident out of a survey sample of 33 residents.The findings included:Resident #2 (R2) was on contact isolation and the facility staff had enhance barrier precautions posted outside the door.On 7/21/25 a tour of nursing unit two was conducted. During the tour it was observed that R2 signage on the outside of his door was for enhanced barrier precautions. Review of the facility matrix R2 was on transmission based precautions. Reviewing the clinical record there was a physician order for R2 to be on contact isolation due to c-difficile (c-diff) infection. A second observation was conducted and enhanced barrier precautions signage was posted outside R2's door.On 07/23/2025 at 11:20 a.m., an interview was conducted with the infection preventionist registered nurse RN#3 (RN3). RN3 stated that R2 should not be on contact precautions that order was supposed to be discontinued. RN3 stated that R2 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, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the flu and pnuemococcal vaccines to two of five residents reviewed for immunizations (Resident #17-R17 and Resident #110-R110). The findings included:On 7/22/2025 at 2:21 p.m., a sample of five residents was selected for review of immunizations. Clinical record reviews were conducted. For R17, according to the clinical record, the resident was admitted on [DATE] and was a resident of the facility during the 2024/2025 flu season. According to the immunization tab of the clinical record, R17's most recent dose of the influenza vaccine was 3/8/23. There was no indication that the facility provided R17 any education nor offered the flu vaccine. R17's chart had no evidence of a consent or declination of the flu vaccine for the 2024/2025 flu season. For R110, whose most recent readmission following hospitalization was 12/26/24. According to the immunization tab of the 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.

Based on staff interviews and facility documentation review the facility staff failed to ensure that staff received required training related to the care of residents with cognitive impairments, including dementia, for two of five staff reviewed for training. The findings included:Two certified nursing assistants were not in compliance with the training requirements for caring for cognitive impaired residents. On 7/24/25 at 8:30 a.m. an interview was conducted with a registered nurse, RN#3 (RN3). RN3 was asked if she was over staff training and she stated she was. Five employee training records were requested, RN3 stated that it was yearly training required and completed on Relias and then she had some in-services as well.On 07/24/2025 at 9:36 a.m. The requested training records for staff was reviewed. Certified nurse assistant (CNA), CNA#4 (CNA4), CNA#5 (CNA5) CNA#6 (CNA6), licensed practical nurse (LPN), LPN#4 (LPN4) LPN#5 (LPN5) training records were reviewed. Two employees, CNA4 and CNA6 out of the five employee records reviewed, did not receive the required training for the…

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

Based on observations, staff interview, clinical record and facility documentation the facility staff failed to follow physician's orders for tube feeding flushes for one resident, (Resident #1, R1) in a survey sample of 4 residents. The findings included: The facility staff failed to administer tube feeding flushes between medications, before the bolus feeding and after the bolus feeding with the volume of water flushes that were ordered by the physician. On 5/21/24 at 10:00 a.m. an observation of a medication and bolus tube feeding being administered to R1 was conducted. During the observation, this surveyor observed LPN#1 (LPN1) administering one liquid medication, one cup with crushed medications diluted with water, a bolus tube feeding, and water flushes. During the observation, LPN1 was not observed flushing the peg tube with 15cc's of water before and between medications and not flushing with 50cc's of water prior to the bolus feeding, but did flush with 120cc's of water after the bolus feeding was completed. On 5/21/24 at 10:30 a.m., an interview was conducted with LPN1.…

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 and accurate clinical record for one of six residents in the survey sample (Resident #6). Resident #6's communication forms for dialysis were incomplete. The findings include: Resident #6 (R6) was admitted to the facility with diagnoses that included end stage renal disease (ESRD) with hemodialysis, anemia, thrombocytopenia, aortic valve stenosis, urinary tract infection, history of Covid-19, history of MRSA (methicillin-resistant staphylococcus aureus), dysphagia, pressure ulcers and atherosclerosis of extremity arteries with ulceration. The minimum data set (MDS) dated [DATE] assessed R6 with severely impaired cognitive skills. Resident #6's clinical record documented a physician's order dated 7/26/23 for hemodialysis twice per week on each Tuesday and Thursday. Resident #6's plan of care (revised 7/25/23) documented the resident was at risk for complications related to hemodialysis. Interventions to…

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

Based on clinical record review, resident interview, and staff interview, the facility staff failed to follow physician's orders for catheterization for one of 29 residents in the survey sample, Resident # 5. Facility staff failed to catheterize the resident as scheduled according to physician's orders. The findings were: Resident # 5 in the survey sample was admitted with diagnoses that included traumatic spinal cord dysfunction, incomplete lesion at C8 level of spinal cord, spinal stenosis, neuromuscular dysfunction of the bladder, neurogenic bladder, hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, morbid obesity, neurogenic bowel, gastroesophageal reflux disease, and history of COVID-19. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 4/4/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Resident # 5 had the following physician's order, IO (In and Out) cath (catheter) q (every) 6 hours for neurogenic bladder. The 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.

Based on review of the facility's personnel files, facility policy and procedures, and staff interviews, the facility staff failed to implement the policy and procedure to ensure applicants for employment completed a Sworn Disclosure Statement disclosing .any criminal convictions or pending criminal charges . and also failed to ensure a criminal background check was obtained within 30 days of hire for one of 25 records reviewed. The findings include: On 04/14/2022 at 8:00 a.m., 25 employee files were reviewed. The files included the facility's administrator's personnel file that did not have a signed Sworn Disclosure Statement to disclose any criminal convictions or pending criminal charges. This identified employee file also did not contain a criminal background report from the State police office within 30 days of hire. On 04/14/2022 at 8:45 a.m., the human resources/payroll manager (OS #7) who was responsible for ensuring the employee files were complete and accurate was interviewed about the missing information. OS #7 stated, I think the information was pulled in Richmond during…

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 document a discharge to the hospital in the clinical record for one of 29 residents, Resident #42. The Findings Include: Resident #42 was admitted to the facility with diagnoses that included: Spleen rupture, congestive heart failure, acute on chronic hypoxic respiratory failure, and muscle weakness. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 2/16/22. Resident #42 was assessed with a cognitive score of 14, indicating cognitively intact. On 4/13/22 Resident #42's medical record was reviewed. The MDS list indicated Resident #42 had been discharged to the hospital on 1/31/22. Review of the progress notes documentation dated 2/1/22 and 2/2/22 read pt (patient) still in hosp (hospital). There were no other progress notes or assessment/discharge notes indicating why Resident #42 had gone to the hospital. Review of the hospital notes documented Resident #42 was admitted to the…

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

Based on clinical record review, staff interview, and resident interview, the facility failed to accurately complete a Minimum Data Set (MDS) for two of twenty-nine (29) residents in the survey sample, Residents # 28 and 29. The facility failed to accurately assess Section C (Cognitive Patterns), Section D (Mood), and Section E (Behavior) for both residents. The findings include: 1. Resident # 28 was admitted with diagnoses that included hypertension, viral hepatitis, hyperlipidemia, cerebrovascular accident, left side hemiplegia, malnutrition, depression, chronic pain, glaucoma, dysphagia, insomnia, and abnormal posture. A review of the most recent Minimum Data Set (MDS), a Quarterly review with an Assessment Reference Date (ARD) of 2/4/2022 found Section C (Cognitive Patterns), Section D (Mood), and Section E (Behavior) was not completed. At approximately 2:00 p.m. on 4/12/2022, Resident # 28 was interviewed. The resident was alert and oriented, and answered all questions appropriately. At 3:50 p.m. on 4/13/2022, the Social Worker (SW), who was identified as responsible for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility failed to review and revise a comprehensive care plan for two of 29 residents, Resident #64 and #92. Resident #64 did not have an ADLs (activities of daily living) care plan updated and Resident #92 did not have code status updated. The Findings Include: 1. Diagnoses for Resident #64 included: Parkinson's disease, urinary tract infection, anxiety, and muscle weakness. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of [DATE]. Resident #64 was assessed with a cognitive score of 15 indicating cognitively intact. Under Section G, Functional Status, Resident #64 was assessed for bed mobility, transfer, eating, and toileting use at a 3-2 for all areas indicating extensive assistance with one person assist. A 5 day MDS assessment with an ARD of [DATE] was reviewed for comparison. Section G, Functional Status indicated bed mobility, transfer, and toileting as a 2-2 indicating limited…

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 assess and initiate treatment for a wound for one of twenty-nine residents in the survey sample, Resident #216; and failed to follow physician orders for one of twenty-nine residents in the survey sample, Resident #49. Resident #216, assessed with a leg wound upon admission, had no treatment orders implemented or ongoing monitoring of the wound. Resident #49 did not have a medication dosage change as ordered by the physician. The findings include: 1. Resident #216 was admitted to the facility with diagnoses that included septic arthritis, cellulitis of left lower leg, sacral pressure ulcer, diabetes, constipation and muscle weakness. The admission nursing assessment dated [DATE] assessed Resident #216 as alert and oriented to time, place and person. Resident #216's admission assessment dated [DATE] documented, .has a pressure wound to the coccyx and a wound from 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.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide a therapeutic diet as ordered by the physician for one of twenty-nine residents in the survey sample, Resident #53. Resident #53 was not provided a double-portioned meal as ordered by the physician due to weight loss. The findings include: Resident #53 was admitted to the facility with diagnoses that included protein-calorie malnutrition, cellulitis of right leg, right foot burn, diabetes, cirrhosis of liver without ascites, dementia, COVID-19, hemiplegia from cerebrovascular accident, hypertension and gastroesophageal reflux disease. The minimum data set (MDS) assessed Resident #53 as cognitively intact. Resident #53's clinical record documented a physician's order dated 3/18/22 for consistent carbohydrate regular diet with double portions. The registered dietitian (RD) documented an evaluation on 3/25/22 listing the resident as underweight with a history of weight loss. The nutrition note documented the resident had good appetite and consumption of greater…

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 medications were available for administration to one of five residents in the medication pass, Resident #84. Calcium carbonate and Natural Balance Tears were not available for administration to Resident #84 during a medication pass. The findings include: A medication pass observation was conducted on 4/12/22 at 4:36 p.m. with licensed practical nurse (LPN) #6 administering medicines to Resident #84. During this observation, LPN #6 prepared and administered Colace 100 mg (milligrams), famotidine 20 mg and gabapentin 300 mg. LPN #6 stated she was unable to give two scheduled medicines as they were not available in the cart or the supply room. LPN #6 identified the omitted medicines as calcium carbonate 600 mg and Natural Balance Tears. Resident #84's clinical record documented a physician's order dated 3/23/22 for calcium carbonate 600 mg twice per day as a supplement and an order dated 2/2/22 for Natural Balance Tears solution 0.1-0.3% with one drop in the right eye two times per day…

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 clinical record review the facility staff failed to ensure a medication error rate of less than 5 percent. There were three errors out of twenty-six opportunities for an error rate of 11.54 percent. Findings include: A medication pass and pour observation was conducted 4/13/22 beginning at 8:15 a.m. with LPN (licensed practical nurse) # 2. LPN # 2 pulled the medications for administration to Resident # 36. The label for Folic Acid 1 mg (milligram) directed Place and dissolve 1 tablet buccally (in the cheek) one time a day for supplement. LPN # 2 was observed pushing the tablet from the pill card into the medicine cup with the other medications to be swallowed by Resident #36. On 4/13/22 at 8:45 a.m., the medications observed as administered to Resident # 36 were reconciled. The current physician order for the Folic Acid matched the label directions (to give bucally). On 4/13/22 at 8:50 a.m. LPN # 2 was asked about the Folic Acid administration, and advised what the order and label directed. LPN # 2 then pulled up…

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

Based on observation, staff interview, and facility document review, the facility staff failed to ensure drugs and biologicals were labeled appropriately on one of three nursing units, Unit 2 medication room. The facility failed to appropriately label one, multi dose vial of Tuberculin on Unit 2. Findings include: On 04/13/22 at 7:30 AM, the Unit 2 medication room was observed with LPN (Licensed Practical Nurse) #1. The refrigerator had one vial of tuberculin medication in it's original box. The vial of tuberculin had been opened and accessed with approximately three quarters of the medication remaining in the vial. Neither the vial of tuberculin, nor the original box had an open date indicating when the the medication had been opened and accessed. LPN #1 stated that the vial of tuberculin should have an open date on it. The manufacturer's label on the vial documented that the medication should be discarded 30 after opening. LPN #1 stated, We don't know when that is because there's not an open date. The policy titled, Storage and Expiration Dating of Medications documented, .Once…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #46 was admitted to the facility with diagnoses that included cerebrovascular accident (stroke) with hemiplegia, hypertension, diabetes, depression and bipolar disorder. The minimum data set (MDS) dated [DATE] assessed Resident #46 as cognitively intact. On 4/12/22 at 11:45 a.m., Resident #46 was interviewed about quality of life in the facility. Resident #42 stated he was not pleased with the food. Resident #46 stated the food doesn't taste good and was most all the time served cold. Resident #42 stated he ate meals in his room and meals more times than not were lukewarm. A test tray was conducted during dinner on 4/12/22 at 6:00 p.m. The test tray evaluation determined that food items were inadequate with temperature and taste at the time of service to residents. This finding was reviewed with the administrator and director of nursing during a meeting on 4/13/22 at 4:30 p.m.Based on resident interview, staff interview, and during a test tray observation, the facility staff failed to ensure food 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 and staff interview the facility staff failed to ensure food preferences were honored for one of 29 resident's in the survey sample, Resident #71. Findings include: Resident #71's most recent MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. The resident's diagnoses included, but were not limited to: CHF (congestive heart failure), atrial fibrillation, gastric reflux, increased lipids, arthritis, depression, and sleep apnea. The resident was assessed as independent for meal consumption with set up only. On 04/12/22 at 12:31 PM, Resident #71 was interviewed and had just finished his lunch. The resident was asked about food. Resident #71 stated that the supper meal is cold and he will often fill out the alternate menu. Resident #71 stated that they serve a lot of french fries and onion rings and stated that he likes vegetables. Resident #71…

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 failed to ensure food in the main kitchen was stored prepared, distributed and served in a safe and sanitary manner. Findings include: On 04/12/22 at 10:30 AM, during the initial tour of the facility kitchen with the DM (dietary manager), the walk in refrigerator was observed. An open container of cottage cheese did not have an open date or use by date. The DM removed the cottage cheese container and disposed of it. The DM was asked if that was supposed to be dated. The DM stated, Yes. Two prepared packages of sliced cheese (approximately 12-16 slices per package) were wrapped in plastic wrap. On each package was a sticker with the prepared date of 04/07/22, but there was no use by date. The DM stated that there should be a use by date on each prepared package of cheese slices. Two partial bags of shredded cheese (one mozzarella and one cheddar), each were wrapped in plastic wrap. The bag of mozzarella had an open date of 04/08/22, but no use by date. The bag of cheddar had an open date of 04/07/22, but…

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 twenty-nine residents in the survey sample, Resident #216. Resident #216's record had conflicting documentation of her resuscitation status. The findings include: Resident #216 was admitted to the facility with diagnoses that included septic arthritis, cellulitis of left lower leg, sacral pressure ulcer, diabetes, constipation and muscle weakness. The admission assessment dated [DATE] assessed Resident #216 as alert and orient to time, place and person. Resident #216's admission assessment dated [DATE] listed the resident as a full code indicating a requirement for cardiopulmonary resuscitation in case of cardiac arrest. The record documented a physician's order dated 4/5/22 stating, Full Resuscitation. The resident's initial care plan (dated 4/5/22) documented the resident as a full code. Resident #216's clinical record also contained a Durable Do Not Resuscitate Order (DDNR) signed 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 observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure the right to retain and use of personal property for one of 27 residents in the survey sample, Resident #209. Resident #209's cell phone was locked in the medication cart for over a week without the resident's permission or knowledge and without identifying the phone as the resident's property. The findings include: Resident #209 was admitted to the facility on [DATE] with diagnoses that included lower limb cellulitis, dementia with behaviors, chronic obstructive pulmonary disease, morbid obesity, high blood pressure, delusional disorder and osteoarthritis. The admission nursing assessment dated [DATE] assessed Resident #209 as alert and oriented to person only. Resident #209's clinical record documented a physician's history and physical note dated 2/10/20 stating, .She [Resident #209] said she slept well however the nurse told me that she did not sleep well last night because she was trying…

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, facility staff failed to develop a baseline care plan for a PICC (peripherally inserted central catheter) line, for one of 27 residents in the survey sample, Resident #318. Findings included: Resident #318 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: UTI with ESBL (urinary tract infection with extended spectrum beta lactamase), PICC Line placement, and Contact Isolation. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 02/18/2020. Resident #318 was assessed as cognitively intact with a total cognitive score of 14 out of 15. Resident #318 was readmitted to the facility on [DATE] with a PICC line in place. This resident was receiving IV (intravenous) antibiotics for a UTI. Resident #318's CCP (comprehensive care plan) was reviewed on 02/19/2020 at approximately 1:00 p.m. No documentation…

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, facility staff failed to develop a comprehensive care plan for one of 27 residents in the survey sample, Resident #318, for care of a PICC (peripherally inserted central catheter) line. Findings included: Resident #318 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: UTI with ESBL (urinary tract infection with extended spectrum beta lactamase), PICC Line placement, and Contact Isolation. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 02/18/2020. Resident #318 was assessed as cognitively intact with a total cognitive score of 14 out of 15. Resident #318 was readmitted to the facility on [DATE] with a PICC line in place. This resident was receiving IV (intravenous) antibiotics for a UTI. Resident #318's CCP (comprehensive care plan) was reviewed on 02/19/2020 at approximately 1:00 p.m. No…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, facility staff failed to obtain a physician order for use of Aspercreme, for one of 27 residents in the survey sample, Resident #321; and failed to coordinate with Hospice services for one of 27 residents, Resident #214. Findings include: 1. Resident #321 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Acute Cholecystitis with drain placement, Difficulty walking, Muscle weakness and Gout. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 12/16/2019. Resident #321 was assessed as moderately impaired in his cognitive status with a total cognitive score of 11 out of 15. Resident #321 was interviewed on 02/18/2020 at 3:05 p.m. Resident #321 was observed sitting up in a chair with a bedside table in front of him. Lying on the table was tube of Aspercreme. Resident #321 stated, I use that when my leg starts aching.…

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 and staff interview, the facility staff failed to ensure sufficient staffing on one of three nursing units (Unit 1) in the facility. Findings include: During the survey on 02/18/20 through 02/20/20, Unit 1 was observed and toured multiple times throughout the survey process. On 02/18/20 at approximately 11:00 AM, during the initial tour of the facility on Unit 1, Resident #21 and her daughter were interviewed. Resident #21 stated that the facility was short staffed and that the CNAs (certified nursing assistants) were doing all they could do. Resident #21stated that she was admitted in November 2019 and was getting rehab services for strengthening. The resident stated that rehab services stopped in January. Resident #21 stated that after rehab therapy ended, she was now supposed to be get restorative services. Resident #21 stated that she had not received any restorative services and that this was attributed to short staffing. Resident #21's daughter stated that she believed her mother wasn't getting restorative because they don't have enough…

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

Based on observation and staff interview, facility staff failed to procure, store and prepare food in a sanitary manner in the main kitchen. Findings included: A tour of the main kitchen was conducted on 02/18/2020 at 10:45 a.m. with the Dietary Manager (DM). A rack of 58 bowls was observed and three (3) were found with dried food debris. The hood over the cooking area was observed with dust particles on the top surface of the hood. Dust was also noted on the chains holding a hanging utensil/pot rack, as well as on top of the rack itself. The can opener was observed with black, sticky, built-up debris. Dust, food particles and debris were noted on the bottom shelves of the food prep tables. In the dry storage room a bag of pancake mix was observed opened, and not sealed or placed in a storage container. The Dietary Manager was interviewed on 02/18/2020 at 11:25 a.m. The Dietary Manager stated, The can opener should go in the dishwasher everyday, clearly it was not. It will be my expectation that everything will be wiped down everyday. I have only been here a little over a week. It…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, facility staff failed to assess one of 27 residents in the survey sample, Resident #321, for self administration of a medication, Aspercreme. Findings included: Resident #321 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Acute Cholecystitis with drain placement, Difficulty walking, Muscle weakness and Gout. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 12/16/2019. Resident #321 was assessed as moderately impaired in his cognitive status with a total cognitive score of 11 out of 15. Resident #321 was interviewed on 02/18/2020 at 3:05 p.m. Resident #321 was observed sitting up in a chair with a bedside table in front of him. Lying on the table was tube of Aspercreme. Resident #321 stated, I use that when my leg starts aching. I rub it on my right knee. It helps a little. During…

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 implement their abuse prevention policies regarding reporting of an allegation of mistreatment/abuse for one of 27 residents in the survey sample. Resident #209's allegations of mistreatment/abuse/misappropriation of property reported to a therapist and a physician were not immediately reported to the administrator as required in their abuse prevention policies for abuse prevention. The findings include: Resident #209 was admitted to the facility on [DATE] with diagnoses that included lower limb cellulitis, dementia with behaviors, chronic obstructive pulmonary disease, morbid obesity, high blood pressure, delusional disorder and osteoarthritis. The admission nursing assessment dated [DATE] assessed Resident #209 as alert and oriented to person only. Resident #209's clinical record documented a physician's history and physical note dated 2/10/20 stating, .She [Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to immediately report to the administrator allegations of mistreatment and potential misappropriation of property for one of 27 residents in the survey sample. Resident #209's report of mistreatment/misappropriation of property to a therapist and a physician were not reported to the administrator. Nursing staff locked Resident #209's personal cell phone in a medication cart without consent and without any report to nursing or facility administration. The findings include: Resident #209 was admitted to the facility on [DATE] with diagnoses that included lower limb cellulitis, dementia with behaviors, chronic obstructive pulmonary disease, morbid obesity, high blood pressure, delusional disorder and osteoarthritis. The admission nursing assessment dated [DATE] assessed Resident #209 as alert and oriented to person only. Resident #209's clinical record documented a physician's history and physical note…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to safely store portable oxygen cylinders for one of 27 residents (Resident #214). Findings include: Resident #214 was admitted to the facility on [DATE] with diagnoses that included metastatic colon cancer, depression, and edema. The admission nursing assessment dated [DATE] assessed Resident #214 as alert and oriented to time, place and person. On 2/18/20 at 11:05 a.m., Resident #214 was observed in his room. Five small oxygen cylinders (6 cubic feet) were stored in the floor against the left wall upon entrance to the room. The cylinders were not secured in any type of rack or cart. Resident #214 was interviewed at this time about the cylinders. Resident #214 stated four of the cylinders were empty and one was full. Resident #214 stated he used the small oxygen tanks when he left the facility for outings and was able to attach the tubing and use the oxygen on his own.…

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

Based on observation, staff interview and facility document review, the facility staff failed to ensure a medication was properly labeled on one of three nursing units. An insulin pen was stored in the medication cart on unit one with no resident name or date opened. The findings include: On 2/19/20 at 2:00 p.m., accompanied by licensed practical nurse (LPN) #3, the medication cart on unit one was inspected. Stored in the cart was an opened and unlabeled Humalog Kwick insulin pen (100 units/milliliter). The insulin pen was not labeled with a resident name and was not marked with the date opened. The pen was stored in a plastic bag along with another insulin pen labeled for a current resident. On 2/19/20 at 2:03 p.m., LPN #3 was interviewed about the unlabeled insulin pen. LPN #3 stated the unlabeled insulin pen was not in the medication cart yesterday (2/18/20). LPN #3 stated, I don't know who put it [insulin pen] there. LPN #3 stated the insulin should have been labeled from the pharmacy with a resident name and nurses were supposed to write the date opened on the label. 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, family interview, clinical record review, and staff interview, the facility staff failed to ensure one of 27 residents received restorative nursing services. Restorative services for Resident #21 was not provided per the PT (Physical Therapist) recommendations and physician's order. Findings include: Resident #21 was admitted to the facility on [DATE]. Diagnoses for Resident #21 included, but were not limited to: osteoarthritis, osteoporosis, muscle weakness, atrial fibrillation, over active bladder and difficulty walking. The resident's most current full MDS (minimum data set) was the admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the resident is intact for daily decision making skills. The resident was assessed as requiring extensive assistance from one staff person for transfers, dressing, toileting and hygiene. The resident was assessed as requiring limited assistance with one staff person for ambulation. On 02/18/20 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 observation, staff interview, facility document review, and clinical record review, facility staff failed to ensure proper infection control practices for contact isolation were implemented for one of 27 residents in the survey sample, Resident #318. Findings included: Resident #318 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: UTI with ESBL (urinary tract infection with extended spectrum beta lactamase), PICC (peripherally inserted central catheter) Line placement, and Contact Isolation. The most recent MDS (minimum data set) was an initial assessment with an ARD (assessment reference date) of 02/18/2020. Resident #318 was assessed as cognitively intact with a total cognitive score of 14 out of 15. The clinical record review included a physician order sheet dated February 2020 documenting, .Contact Isolation for ESBL in urine . The current comprehensive care plan documented: .has a potential for impaired social interaction 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.