Autumn Care Of Chesapeake

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a medication pass observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration to three (3) of 55 residents in the survey sample (Resident #69, #26, #85) and during a medication pass on one of four units (100 unit). The findings include: 1. Resident #69's medication Janumet was not available for administration resulting in five missed doses of the medication. Resident #69 (R69) was admitted to the facility with diagnoses that included diabetes, cerebral infarction, dysarthria, hypertension, protein-calorie malnutrition and dysphagia. The minimum data set (MDS) dated [DATE] assessed R69 as cognitively intact. Resident #69's clinical record documented a physician's order dated [DATE] for the medication Janumet 50-1000 mg (milligrams) one tablet by mouth two times per day for type 2 diabetes. A physician's order was documented on [DATE] for Janumet 50-1000 mg two times per day via gastric tube for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location, accessible to designated staff for 7 of 55 residents: Resident #7, Resident #85, Resident #42, Resident #54, Resident #77, Resident #51 and Resident #78 in the survey sample. The findings included: 1. The facility staff failed to ensure Hydrocortisone cream 1 percent (%) was stored in a secured location, accessible to designated staff only. Resident #7 was admitted to the facility on [DATE]. Diagnosis for Resident #7 included but not limited to major depressive disorder. Resident #7's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 09/14/23, under cognitive status was not coded on the Brief Interview for Mental Status (BIMS) but was coded as independent for decisions being consistent and reasonable. During the initial tour of the facility on 12/05/23 at approximately 1:59 p.m., observed on 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 family interview, staff interviews and clinical record review, the facility staff failed to ensure transportation arrangements were made for 1 resident's dental appointment in a survey sample of 55 residents (Resident #1). The findings included: Resident #1 was originally admitted to the facility on [DATE]. The current diagnoses included cerebral palsy. The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/07/23 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionGG(Physical functioning) the resident was coded as being dependent on staff for eating, oral hygiene, toileting, shower and bathing. The person centered care plan created on 8/03/21 read Resident #1 has a potential oral health problem. The goal set for the resident was they will have proper nutrition and hydration…

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 have advanced directives accessible for five resident's (Resident #68, #14, #7, #45 and #84) in a survey sample of 37 residents. The findings included; 1. Resident #68 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #14 included but not limited to Type 2 diabetes Mellitus and Muscle Weakness. The current Minimum Data Set (MDS), a Quarterly Revision assessment with an Assessment Reference Date (ARD) of 12/08/2019. The staff assessment for mental Status coded the Resident as having Short term and Long term memory problems. Section C1000-Coded the Resident's Cognitive Skills for Decision Making as being severely impaired. A review of the clinical record on 01/08/2019 revealed there was no advanced directive in the clinical record concerning an advance directive. On 1/9/20 at 1:45 p.m., an interview was conducted with OSM (other staff member) #4 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 observation, staff interview, and facility document review, the facility staff failed to ensure Registered Nurse (RN) coverage for 8 hours, 7 days a week. The facility staff failed to ensure RN coverage for 8 hours for four days. The findings included: On 01/09/20 at approximately 2:00 PM, the facility's actual worked schedule was reviewed with the DON (Director of Nursing) and revealed there was no RN coverage for the following days: 1/19/19, 1/20/19, 5/5/19, 5/27/19. The DON was asked what should have been done concerning providing Registered Nursing Coverage? He stated, We should have gotten RN coverage. On 01/09/20 at approximately, 7:12 PM a pre-exit interview was conducted with The Director of Nursing (DON), the ADON (Assistant Director of Nursing) and the facility Administrator concerning the above issue. No further information was provided by the facility staff.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and clinical record review the facility staff failed to ensure the quarterly Minimum Data Set (MDS) assessment accurately reflected 1 of 37 residents in the survey sample, Resident #48. The findings included: Resident #48 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Alzheimer's Disease With Late Onset and Anxiety Disorder. Resident #48's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 11/21/2019 coded Resident #48 with a BIMS (Brief Interview for Mental Status) score of 03. indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #48 as requiring extensive assistance of 1 with eating, total dependence with assistance of 1 for dressing, personal hygiene and bathing and total dependence with assistance of 2 for bed mobility, transfer and toilet use. On 01/09/2019 at approximately 4:30 p.m., review of Resident #48's clinical record revealed the following: Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to follow physician orders and the comprehensive care plan for oxygen administration for one of 37 residents in the survey sample, Resident #12. The facility staff failed to administer the correct amount of oxygen per nasal cannula. The findings included: Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. Resident #12's most recent MDS (minimum data set) assessment was a Quarterly Revision assessment with an ARD (assessment reference date) of 10/10/19. Resident #12 was coded as being intact in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #12 was coded in section O, Special Treatments and Programs, as receiving respiratory therapy. Review of Resident #12's POS…

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, it was determined that facility staff failed to follow orders to change the nebulizer tubing every 7 days as ordered and failed to administer oxygen per physician orders, for one of 37 residents in the survey sample, Resident #12. The findings included: 1a. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. Resident #12's most recent MDS (minimum data set) assessment was a Quarterly Revision assessment with an ARD (assessment reference date) of 10/10/19. Resident #12 was coded as being intact in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #12 was coded in section O, Special Treatments and Programs, as receiving respiratory therapy. Review of Resident #12's POS (physician order summary) dated 12/27/ 2019,…

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 and facility documentation, the facility staff failed to ensure infection control practices were followed during wound care for 1 of 37 residents in the survey sample, Resident #302. The findings included: Resident #302 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Cerebral Ischemia and Unspecified Severe Protein-Calorie Malnutrition. Resident #302's Nurse admission Evaluation with an evaluation date of 12/30/2019 revealed that the resident was AOx4 (Alert and Oriented times 4). In addition, the Nurse admission Evaluation revealed that the resident was evaluated as requiring assistance of 1 with ADL's (Activities of Daily Living). On 01/08/2020 at 11:35 a.m., Resident #302's wound care was observed. Licensed Practical Nurse (LPN) #3, Wound Care Nurse, was assisting the physician during wound care. LPN #3 performed hand hygiene and then placed a barrier on the bedside table top. LPN #3 obtained needed wound care supplies from 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 5. For Resident #35 the facility staff failed to ensure Foley catheter tubing was anchored. Resident #35 was admitted to the facility on [DATE]. Diagnoses included but not limited to unspecified dementia with behavioral disturbance, heart failure, pressure ulcer of sacral region, and encounter for palliative care. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 08/17/18 coded the Resident 00 of 15 in section C, cognitive patterns. Resident #35's CCP (comprehensive care plan) was reviewed and contained a focus area of requires urinary catheter related to wound on sacrum. Interventions included but were not limited to, maintain drainage bag below the bladder level, and change catheter and draining system as indicated by the physician. Resident #35's clinical record was reviewed on 10/17/18. It contained a physician's order summary which read in part, Anchor catheter tubing and check placement every shift. Resident #35 was observed by the surveyor on 10/16/18 at approximately 11:02…

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 3. The facility staff failed to ensure Resident # 21's insulin (Basaglar) was available for administration. The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without hepatic coma, and cerebral infarction due to embolism. Resident #21's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #21's current…

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 9 of 26 Residents were free of unnecessary medications. Residents #66, #89, #90, #100, #21, #28, #33, #59, #42. The findings included: 1. For Resident #66, staff failed to ensure the resident received an anti-psychotic medication only to treat specific conditions and symptoms as documented in the clinical record. Resident #66 was admitted to the facility on [DATE] with diagnoses including muscle weakness, dysphagia, dementia in other diseases classified elsewhere without behavioral disturbance, cerebral infarction due to embolism of other cerebral artery, type II diabetes mellitus without complications, essential primary hypertension, other specified anxiety disorders, major depressive disorders, insomnia, and chest pain. On the quarterly minimum data set assessment with assessment reference date 9/17/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to ensure call bell was in reach for 1 of 26 Residents, Resident #31. The findings include: The facility staff failed to ensure that that the call bell remained within reach for Resident # 31. Resident # 31 is a [AGE] year-old-female who was originally admitted to the facility on [DATE] with a readmission date of 11/07/17. Diagnoses included but were not limited to muscle weakness, type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and unspecified fracture of sacrum. The clinical record for Resident #31 was reviewed on 11/16/18 at approximately 3:23pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 08/14/18 coded the Resident as 15 of 15 in section C, cognitive patterns. Section G assesses functional status. In Section G0110, the facility staff documented that Resident #31 required extensive assistance 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.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate DDNR (durable do not resuscitate) order for 1 of 26 Residents Resident #8. The findings included: The facility staff failed to ensure the Residents DDNR was complete. Section's 1 and 2 had been left blank. The clinical record review revealed that Resident #8 had been admitted to the facility 08/13/13. Diagnoses included, but were not limited to, Alzheimer's disease, hypothyroidism, nutritional deficiency, chronic pain syndrome, hypertension, and heart failure. Section C (cognitive patterns) of the Residents significant change MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/06/18 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. Section O (special treatments, procedures, and programs) had been coded to indicate the Resident was receiving hospice services. The Residents clinical record included a DDNR order form from the Virginia Department…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide advance notice of end of coverage in regards to medicare benefits for 1 of 26 Residents, Resident #74. The findings included: The facility failed to provide Resident #74 advance notice that the medicare part A services were ending. The clinical record review revealed that Resident #74 had been readmitted to the facility 03/23/18. Diagnoses included, but were not limited to, muscle weakness, nutritional deficiency, major depressive disorder, chronic pain, anxiety disorder, glaucoma, and bipolar disorder. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/27/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. Resident #74 was one of three residents chosen for the task beneficiary protection notification review. The facility provided the surveyor with two forms regarding this task and this resident: 1. SNFABN (skilled nursing facility…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to complete a discharge MDS (minimum data set) assessment for 1 of 26 Residents, Resident #2. The findings included: The facility failed to complete a discharge MDS assessment. The Resident had been discharged from the facility on 06/29/18. The record review revealed that Resident #2 had been admitted to the facility on [DATE], readmitted on [DATE], and discharged on 06/29/18. Diagnoses included, but were not limited to, muscle weakness, dysphagia, depressive disorder, heart failure, and hypertension. Section C (cognitive patterns) of the Residents quarterly MDS assessment with an ARD (assessment reference date) of 05/21/18 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points. Resident #2 was flagged in the long-term care survey process as having an overdue MDS assessment. A review of the EHR (electronic health record) revealed that this Resident had been discharged from the facility on…

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

Based on staff interview and clinical record review the facility failed to complete a level 1 PASARR (preadmission screening and annual resident review) for 1 of 26 Residents, Resident #74. The findings included: The facility failed to ensure a level 1 PASARR was completed. A PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long-term care. The clinical record review revealed that Resident #74 had been readmitted to the facility 03/23/18. Diagnoses included, but were not limited to, muscle weakness, nutritional deficiency, major depressive disorder, chronic pain, anxiety disorder, glaucoma, and bipolar disorder. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/27/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. During the clinical record review, the surveyor was unable to locate a PASARR in the Residents EHR (electronic health record). On 10/16/18 at 4:43 p.m., the surveyor…

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 2 of 26 residents (Resident #33 and Resident #66). The findings included: 1. The facility staff failed to develop a care plan for comfort care for Resident #33. The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infection, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder. Resident #33's significant change in minimum data set (MDS) with an assessment reference date (ARD) of 8/16/18 assessed the resident with a BIMS (brief interview for mental status) as 12 out of 15 in Section C. The October 2018 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide mouth care to 1 of 26 residents (Resident #59). The findings included: The facility staff failed to provide mouth care to Resident #59. The clinical record of Resident #59 was reviewed 10/16/18 through 10/18/18. Resident #59 was admitted to the facility 8/12/17 and readmitted [DATE] with diagnoses that included but not limited to metabolic encephalopathy, severe sepsis with shock, dysphagia, neuromuscular dysfunction of the bladder, hypertension, atherosclerotic heart disease, obsessive compulsive personality disorder, rhabdomyolysis, end stage renal disease, anxiety disorder, mental disorder, repeated falls, hyperkalemia, urinary tract infection, Parkinson's disease, and major depressive disorder. Resident #59's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/12/18 assessed the resident with a BIMS (brief interview for mental status) as 9/15. Section…

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, resident interview, facility document review, and clinical record review, it was determined that facility staff failed to follow physician's orders for 1 of 25 Residents in the survey sample, Resident # 90. The findings included: The facility staff failed to follow physician's orders for dressing changes twice a day for Resident # 90. Resident # 90 was an [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmission date of 3/5/18. Diagnoses included but were not limited to: osteoarthritis, cellulitis of right lower limb, hypertension, and non-pressure chronic ulcer of right lower leg. The clinical record for Resident # 90 was reviewed on 10/17/18 at 9:51 am. The most recent MDS assessment (minimum data set) was a quarterly assessment with an ARD date (assessment reference date) of 9/28/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 90 had a BIMS score (brief interview for mental…

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 provide appropriate treatments for pressure ulcers for 3 of 26 residents (Resident #33, Resident #56 and Resident #97). The findings included: 1. The facility staff failed to provide treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from forming for Resident #33. The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infection, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder. Resident #33's significant change in minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure a hazard free environment for 1 of 26 residents (Resident #28). The findings included: The facility staff failed to follow the physician order for bilateral floor mats for Resident #28. The clinical record of Resident #28 was reviewed 10/16/18 through 10/18/18. Resident #28 was admitted to the facility 9/7/16 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, dysphagia, right shoulder contracture, major depressive disorder, Type 2 diabetes mellitus, seizures, iron deficiency anemia, urine retention, anxiety disorder, moderate protein calorie malnutrition, peripheral vascular disease, gastroesophageal reflux disease, bradycardia, diabetic neuropathy, chronic pain syndrome, paraplegia, acute renal failure, gastritis, bacteremia, hyperkalemia, insomnia, and hypertension. Resident #28's quarterly minimum data set (MDS) assessment with an assessment…

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 obtain orders in regards to PICC line dressing changes for 1 of 26 Residents in the survey sample, Resident # 100. The findings included: The facility staff failed to ensure that Resident # 100 had orders for PICC (peripherally inserted central catheter) line dressing changes. Resident # 100 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: MRSA (methicillin-resistant staphylococcus aureus), Parkinson's disease, schizophrenia, and muscle weakness. The clinical record for Resident # 100 was reviewed on 10/16/18 at 11:22 am. During the time of the survey, there was no completed MDS assessment (minimum data set) for Resident # 100. The plan of care for Resident # 100 was reviewed and revised on 10/16/18. The facility staff documented a focus area for Resident # 100 as, Resident # 100 is on antibiotic therapy related to MRSA to left elbow.…

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 provide non-pharmacological interventions in regards to pain management for 3 of 26 Residents in the survey sample, Resident #100, Resident #90, and Resident #21. The findings included: 1. The facility staff failed to provided non-pharmacological interventions prior to the administration of PRN (as needed) pain medication for Resident # 100. Resident # 100 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: MRSA (methicillin-resistant staphylococcus aureus), Parkinson's disease, schizophrenia, and muscle weakness. The clinical record for Resident # 100 was reviewed on 10/16/18 at 11:22 am. During the time of the survey, there was no completed MDS assessment (minimum data set) for Resident # 100. The current plan of care for Resident # 100 was reviewed and revised on 10/15.18. The facility staff documented a focus area for Resident # 100 as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Facility staff failed to address the resident's dementia and its treatment with antipsychotic medications in the plan of care for 1 of 26 residents in the survey sample (Resident #66). The findings included: Resident #66 was admitted to the facility on [DATE] with diagnoses including muscle weakness, dysphagia, dementia in other diseases classified elsewhere without behavioral disturbance, cerebral infarction due to embolism of other cerebral artery, type II diabetes mellitus without complications, essential primary hypertension, other specified anxiety disorders, major depressive disorders, insomnia, and chest pain. On the quarterly minimum data set assessment with assessment reference date 9/17/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident's medication assessment was coded under Medications received (N0410 A) as receiving anti-psychotic medications 7 of the 7 days prior 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to follow up on pharmacy recommendations for 1 of 26 Residents, Resident #35. Findings included: For Resident #35, the facility failed to provide evidence that the attending nurse practitioner had reviewed a pharmacy recommendation dated 08/23/18. Resident #35 was admitted to the facility on [DATE]. Diagnoses included but not limited to unspecified dementia with behavioral disturbance, heart failure, pressure ulcer of sacral region, and encounter for palliative care. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 08/17/18 coded the Resident 00 of 15 in section C, cognitive patterns. The DON (director of nursing) provided the surveyor with a copy of a pharmacy recommendation dated 08/23/18. The attending nurse practitioner that it was addressed to had not signed the recommendation. On 10/18/18 at approximately 2:30pm, the DON (director of nursing) verbalized to the surveyor that a pharmacy review 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 1 of 26 residents was free of an unnecessary medication (Resident #33). The findings included: The facility staff failed to follow the physician ordered parameters for the administration of Metoprolol for Resident #33. The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infections, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder. Resident #33's significant change in minimum data set (MDS) with an assessment reference date (ARD) of 8/16/18 assessed the resident with a BIMS (brief interview for mental status) as 12 out of 15 in Section C.…

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

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 28 opportunities for a medication error rate of 7.14%. These errors effected Resident #101. The findings included: The facility nursing staff failed to administer the Residents miralax and eye drops. The record review revealed that Resident #101 had been admitted to the facility 10/15/18. Diagnoses included, but were not limited to, diabetes, blindness left eye, transient ischemic attack and cerebral infarcon without residual deficits, and acute appendicitis. There was no completed MDS (minimum data set) assessment completed on this Resident. The Resident was alert and orientated. On 10/17/18 beginning at approximately 7:53 a.m., the surveyor observed LPN (licensed practical nurse) #2 prepare and administer the following medications amlodipine, carvedilol, furosemide, lisinopril, cipro, iron, aspirin, thera tab vitamin, and a PPD to Resident #101. After observing the medication…

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 2 of 26 Residents were free of significant medication errors. Residents #72 and #21 Findings included: 1. For Resident #72 the facility staff failed to administer blood pressure medication as ordered by the physician. Resident #72 was admitted to the facility on [DATE]. Diagnoses included but not limited to hypertension, diabetes mellitus, depression, cerebral infarction due to embolism, and chronic kidney disease. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 09/26/18 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS. Resident #72's CCP (comprehensive care plan) was reviewed and contained a focus area for Resident has altered cardiac status, has interventions that included but were not limited to, Administer medications as directed by the physician. Resident #72's clinical record was reviewed on 10/17/18. It contained a POS (physician's 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 staff interview and clinical record review, the facility staff failed to obtain physician ordered laboratory tests for 3 of 26 residents (Resident #21, Resident #33, and Resident #56). The findings included: 1. The facility staff failed to obtain a physician ordered urinalysis, culture, and sensitivity for Resident #21. The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without hepatic coma, and cerebral…

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 obtain a physician order prior to obtaining laboratory tests for 1 of 26 residents (Resident #59). The findings included: The facility staff failed to obtain a physician order before the CBC (complete blood count) and BMP (basic metabolic panel) were obtained on 9/18/18 for Resident #59. The clinical record of Resident #59 was reviewed 10/16/18 through 10/18/18. Resident #59 was admitted to the facility 8/12/17 and readmitted [DATE] with diagnoses that included but not limited to metabolic encephalopathy, severe sepsis with shock, dysphagia, neuromuscular dysfunction of the bladder, hypertension, atherosclerotic heart disease, obsessive compulsive personality disorder, rhabdomyolysis, end stage renal disease, anxiety disorder, mental disorder, repeated falls, hyperkalemia, urinary tract infection, Parkinson's disease, and major depressive disorder. Resident #59's quarterly minimum data set (MDS) assessment with an assessment…

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 3 of 26 Residents, Residents #21, #31, and #249. The findings included: 1. The facility staff failed to ensure the physician's orders for PROM (passive range of motion) were entered into the computer accurately for Resident #21. The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without…

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.