Chesapeake Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview and staff interviews, the facility staff failed to procure narcotics timely for one resident (Resident #138) in a survey sample of 58 residents. The findings included: Resident #138 was originally admitted to the facility 02/07/2021 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Chronic Pain Syndrome and Pain Unspecified. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/12/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #138 cognitive abilities for daily decision making were intact. In section G(Physical functioning) the resident was coded as independent set-up help only with transfers, walking in the room, locomotion on and off the unit, eating and bathing. Requiring supervision after set-up help only with dressing and personal hygiene. Requiring…

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, clinical record review, and staff interviews, the facility staff failed to ensure the resident was free from significant medication error (the staff failed to administer the intravenous (IV) antibiotic (Cefazolin 2 grams IV every 8 hours) as ordered from 11/16/21 through 12/2/21 for 1 of 58 residents (#55), in the survey sample The findings include: Resident #55 was originally admitted to the facility 10/14/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; diabetes, a stroke with left hemiparesis and Methicillin Susceptible Staphylococcus Aureus (MSSA) related to a left arm abscess. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/18/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #55's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded 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.

Based on staff interviews, clinical record review and the facility's policy, the facility staff failed to follow physician orders for laboratory services for 3 out of 58 residents (Resident #13, Resident #17 and Resident #170) in the survey sample. The findings included: 1. The facility staff failed to obtain Resident #13's blood work ordered on 11/01/21 for Complete Blood Count (CBC) and Basic Metabolic Panel (BMP). Resident #13 was originally admitted the nursing facility on 07/27/21. Diagnosis for Resident #13 included but not limited to Type II Diabetes and long term use of anticoagulants (blood thinner). The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 08/29/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 03 of 15 indicating severe cognitive impairment. Resident #13 was coded total dependence of one with bathing, extensive assistance of one with transfer, dressing, hygiene, bed mobility and toilet use and supervision with setup with eating for Activities of Daily Living (ADL) care. Review of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, family interview, staff interview, and clinical record review, the facility staff failed to accommodate the resident's foods preferences to meet nutritional needs for 1 of 58 residents (Resident #123), in the survey sample. The findings included: Resident #123 was originally admitted to the facility 9/28/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; diabetes, heart failure, , renal insufficiency and status post left great toe amputation. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/4/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #123's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with transfers, extensive assistance of one person…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide documentation in the resident's clinical record of the influenza vaccine administration or the refusal of or medical contraindications to vaccines for 2 of 58 residents (Resident #129 and 112), in the survey sample. The findings included: 1. Resident #129 was originally admitted to the facility 11/11/21 and was discharged home 12/9/21. The current diagnoses included; COPD, hypertension, coronary, artery disease and a major depression disorder. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #129's cognitive abilities for daily decision making were moderately impaired. An interview was conducted with Resident #129 on 12/8/21 at approximately 11:25 a.m. The resident stated she would be discharged home on [DATE] after…

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, the facility staff failed to provide evidence of the facility's COVID-19 recommended frequency of twice a week staff testing to include agency employees based on the level of community transmission. The findings included: An interview was conducted with the Infection Preventionist (IP) and Director of Nursing (DON) on 12/09/21 at approximately 3:30 p.m. The DON said, there's no COVID-19 cases in the building. The DON stated, Vaccinated staff does not require testing but all unvaccinated staff are to be tested twice a week based on the community transmission. When asked if the facility has agency staffing in the building, the DON replied, Yes. When asked if they have their vaccination status, the DON replied, No, it's been requested from the agency but have not yet been received. The (IP) and DON were asked to provide the last 2 weeks of the as-worked schedule to include all agency staffing and to provide a copy of their vaccination status or their twice a week COVID-19 testing. On 12/10/21 at approximately 10:35 a.m., and again…

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 interviews and clinical record review, the facility staff failed to promptly provide 1 out of 58 resident's (Resident #27) the services needed to meet their dental needs after knowing about broken dentures. The findings included: Resident #27 was originally admitted the nursing facility on 07/10/18. Diagnosis for Resident #27 included but not limited to Gastro-Esophageal Reflex Disease (GERD) and Iron Deficiency Anemia. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 09/16/21 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15, which indicated no cognitive impairment for daily decision-making. The MDS coded Resident #27 supervision with eating. A significant change MDS was completed on 02/05/21. Under section L0200 (Dental) was coded for no natural teeth or tooth fragment(s) (edentulous). Review of Resident 27's admission Assessment/Screening document dated 07/10/18 documented the following under mouth: gums are pink/moist…

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, review of facility documents and during the course of a complaint investigation, the facility's staff failed to accurately document in one residents medical record for 1 of 58 residents (Resident #167), a closed record, in the survey sample. The findings included: Resident #167 was originally admitted to the facility 06/15/21 and discharged on 06/26/21 to an acute care hospital. The current diagnoses included; Cerebral Infarction and Aphasia. The discharge, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/26/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for short term memory problems as well as moderately impaired for daily decision making. In section G(Physical functioning) the resident was coded as requiring extensive assistance with bed mobility and eating. Requires total dependence with transfers, locomotion on the unit, dressing, toilet use…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide documentation in the resident's clinical record of the COVID-19 vaccine administration or the refusal of or medical contraindications to vaccines for 1 of 58 residents (Resident #129), in the survey sample. The findings included: Resident #129 was originally admitted to the facility 11/11/21 and was discharged home 12/9/21. The current diagnoses included; COPD, hypertension, coronary, artery disease and a major depression disorder. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #129's cognitive abilities for daily decision making were moderately impaired. An interview was conducted with Resident #129 on 12/8/21 at approximately 11:25 a.m. The resident stated she would be discharged home on [DATE] after 5:00 p.m.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. Resident #139 was a [AGE] year old admitted originally to the facility on 4/30/19 and readmitted on [DATE]. resident #139's diagnoses included but were not limited to, Congestive Heart Failure and Chronic Kidney Disease. The most recent comprehensive Minimum Data Set (MDS) assessment was a admission 5 Day with an Assessment Reference date (ARD) of 5/27/19. The Brief Interview for Mental Status (BIMS) was an 11 out of a possible 15 indicating Resident #139 was cognitively intact and capable of daily decision making. Resident #139's MDS transmit history was reviewed and is documented as follows: 5/9/2019 Discharge Assessment-Return Anticipated, Unplanned. 5/20/19 Re-Entry from Acute Hospital. Resident #139's Progress Notes were reviewed and are documented in part, as follows: 5/9/2019 at 12:43 P.M.: Change of Condition: CNA (Certified Nursing Assistant) went in to give patient lunch tray. Patient called for nurse, on observation patient had uncontrollable tremors. he stated he could not get warm. NP (Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Resident #139 was a [AGE] year old admitted originally to the facility on 4/30/19 and readmitted on [DATE]. Resident #139's diagnoses included but were not limited to, Congestive Heart Failure and Chronic Kidney Disease. The most recent comprehensive Minimum Data Set (MDS) assessment was a admission 5 Day with an Assessment Reference date (ARD) of 5/27/19. The Brief Interview for Mental Status (BIMS) was an 11 out of a possible 15 indicating Resident #139 was cognitively intact and capable of daily decision making. Resident #139's MDS transmit history was reviewed and is documented as follows: 5/9/2019 Discharge Assessment-Return Anticipated, Unplanned. 5/20/19 Re-Entry from Acute Hospital. Resident #139's Progress Notes were reviewed and are documented in part, as follows: 5/9/2019 at 12:43 P.M.: Change of Condition: CNA (Certified Nursing Assistant) went in to give patient lunch tray. Patient called for nurse, on observation patient had uncontrollable tremors. he stated he could not get warm. NP (Nurse…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, Resident interview, staff interviews, facility document review, and clinical record review, the facility staff failed to follow professional standards of nursing practices for 3 out of 63 residents (Residents #99, 421 and 47). 1. The facility staff failed to follow the physician orders for the administration of [NAME] hose for Resident #99. 2. The facility staff failed to obtain daily weights per physician orders starting on 06/06/19 for Resident #421. 3a. For Resident #47, facility staff failed to notify the physician for weight gain greater than 2 pounds on 5/29/19 per physician's order. 3b. For Resident #47, facility staff failed to accurately assess blisters to her right foot and implement a physician ordered treatment. The findings included: 1. Resident #99 was admitted to the facility on [DATE]. Diagnoses for Resident #99 included but not limited to *Type II Diabetes, *Congestive Heart Failure, *Edema and *Embolism. The current Minimum Data Set (MDS), a quarterly assessment with an…

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 information during a complaint investigation, clinical record review, staff interviews the facility staff failed to ensure 1 of 63 residents (Resident #174) in the survey sample maintained a normal bowel elimination pattern. The facility staff failed to ensure Resident #174 maintained a normal bowel elimination at least every 3 days. Resident #174 went 6 days without having a bowel movement. The findings included: Resident #174 was originally admitted to the facility on [DATE]. Diagnosis for Resident #174 included but not limited to *Amotrophic lateral Sclerosis (ALS), Constipation, Neurogenic Bladder and Small Bowel Obstruction. Resident #174's Minimum Data Set (MDS) with an Assessment Reference Date of 06/09/18 coded Resident # 174 Brief Interview for Mental Status (BIMS) score of 15 out of a possible score of 15 indicating no cognitive impairment. In addition, the MDS coded Resident #174 total dependence of two with bed mobility, dressing, personal hygiene, bathing and toilet use, total dependence of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure pain management was provided to 2 of 63 residents in the survey sample (Residents #30 and #47) consistent with professional standards of practice, and the comprehensive person-centered care plan. 1a. For Resident #30, facility staff failed to document the location of pain; and attempt non-pharmacological pain interventions prior to the administration of PRN (as needed) pain medication on several occasions in May and June 2019. 1b. For Resident #30, facility staff failed to clarify two different orders for as needed (PRN) pain medications. 2. For Resident #47, facility staff failed to document the location of pain; and failed to attempt non-pharmacological pain interventions prior to the administration of PRN (as needed) pain medication on several occasions in May of 2019. The findings include: 1a. Resident #30 was admitted to the facility on [DATE] and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and facility document review, it was determined that facility staff failed to ensure residents were free from unnecessary pain medications for two of 63 residents in the survey sample, Resident #30 and #47. 1. For Resident #30, facility staff failed to attempt and/or offer non-pharmacological interventions prior to the administration of pain medication on several occasions in May and June of 2019. 2. For Resident #47, facility staff failed to attempt and/or offer non-pharmacological interventions prior to the administration of pain medication on several occasions in May of 2019. The findings include: 1. Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to urinary tract infection, syncope (fainting) and collapse, and atrial fibrillation. Resident #30's most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/15/19. 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.

The facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility staff failed to store and label food in a safe, sanitary manner. The findings included: On 06/04/2019 at 3:05 p.m., during the initial tour of the kitchen, the surveyor was escorted into the walk in freezer and the following observations were made: an open box of Tilapia Fillets, uncovered and not labeled; an opened, unsealed, and unlabeled bag of broccoli sitting on top of egg patties in a box; an opened box of egg patties not dated; and a second box of egg patties also observed to be opened, unsealed and not dated. The Dietary Aide stated, That's crazy. Broccoli, egg patties and Tilapia should be covered. On 06/10/2019 at 10:20 a.m., an interview was conducted with the Dietary Manager and he was asked, What should happen when a case of food is opened? The Dietary Manager stated, The box should be dated when it is opened and when it is to be used by. The Dietary Manager was asked, Should the bag of broccoli have been closed? 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, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to enhance and promote dignity for 7 residents during the dining experience in the Day Room on Unit 2 in the following ways: 1. Meals were served in an institutional manner to Residents on trays. 2. Certified Nursing Assistant #2 (CNA) was standing with her hands on her hips while feeding a resident. 3. CNA #1, CNA #2, CNA #3 stood while feeding Residents. 4. CNAs placed clothing protectors on Residents without asking their permission. 5. CNA #2 turned off the TV because she felt a resident wasn't eating due to the TV being on. 6. CNA #2 was putting too much food on a spoon to feed a resident and not waiting for the resident to chew and swallow her food before giving her something to drink or eat. The findings included: On 06/07/2019 at approximately 1:08 PM, a Resident's family member approached surveyor in the conference room with concerns that her mother, Resident #124, would be left alone in…

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, the facility staff failed to provide a homelike environment during the dining observation on 06/07/19 in the Day room on unit two. Facility staff served resident meals on trays during the dining observation in the Day Room on unit one for lunch. The findings include: On 06/07/19 at 1:08 p.m., observation of dining in the Day Room was conducted. Seven residents were observed sitting in the activity room waiting for their meals. On 06/07/19 at 1:25 p.m., six residents were served their meals on trays. On 06/07/19 at approximately 2:06 PM an interview was conducted with LPN #9 (Unit Manager). Who stated Everyone had their trays in front of them. It would look better if they took the trays off. LPN #9 stated it was a Dignity Issue. On 06/07/2019 at approximately 2:30 PM interviews were conducted with CNA #1 and CNA #2. They were interviewed separately in the conference room concerning the above issues: CNA #1 was asked if meals should be served on trays? She stated that It's okay to keep food on trays for restorative care residents. CNA #2 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 that 1 resident (Resident #148) of 63 residents in the survey sample, had a Preadmission Screening and Resident Review (PASRR). The findings included: Resident #148 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Diffuse Large B-Cell Lymphoma, unspecified site and Type 2 Diabetes Mellitus. Resident #148's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/22/2019 was coded with a BIMS (Brief Interview of Mental Status) score of 05 indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #148 as requiring extensive assistance of 1 for eating and dressing, extensive assistance of 2 for bed mobility, transfer and toilet use and total dependence of 1 for personal hygiene and bathing. On 06/06/2019 at approximately 4:40 p.m., an interview was conducted with the Social Worker and she was asked, Does Resident #148 have a PASRR level…

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 person-centered care plan for 1 resident (Resident #148) of 63 residents in the survey sample. The facility staff failed to develop a comprehensive person-centered care plan to include Diabetes Mellitus for Resident #148. The findings included: Resident #148 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, *Type 2 Diabetes Mellitus and Diffuse Large B-Cell Lymphoma, unspecified site. Resident #148's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 05/22/2019 coded the resident with a BIMS (Brief Interview of Mental Status) score of 05 indicating severe cognitive impairment. In addition, the MDS coded Resident #148 as requiring extensive assistance of 1 for eating and dressing, extensive assistance of 2 for bed mobility, transfer and toilet use and total dependence of 1 for personal hygiene and bathing. Resident #148's MDS was also coded…

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 review and revise the care plan for three of 63 residents in the survey sample, Residents #47, 35 and 78. 1. For Resident #47, facility staff failed to review and revise the care plan when she acquired two blisters to her right medial and dorsum foot on 5/17/19, when the blisters had opened with a new treatment order, and when the blisters had resolved. 2. For Resident #35, facility staff failed to revise his care plan with a new diagnosis of COPD (chronic obstructive pulmonary disease) and his new order for oxygen. 3. The facility staff failed to revise the comprehensive care plan to to include how often to release a wheel chair seat belt used for Resident #78. The findings include: 1. Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to heart failure, chronic obstructive pulmonary disease, type two…

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 interview, staff interviews, medical record review, and facility documentation review the facility staff failed to ensure that activities of daily living necessary to maintain personal grooming was provided for 1 of 63 residents in the survey sample, Resident #48. The facility staff failed to ensure that fingernail and facial hair care was provided to Resident #48 who was unable to carry out these activity of daily grooming tasks independently. The findings included: Resident #48 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to, generalized muscle weakness, legal blindness and dementia. The most recent comprehensive Minimum Data Set (MDS) assessment is a Significant Change with an Assessment Reference Date (ARD) of 3/18/19. Resident #48's Brief Interview for Mental Status (BIMS) was a a 6 out of a possible 15 indicating the resident was cognitively impaired but capable of some daily decision making. Under Section B Hearing,…

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 interviews and clinical record review the facility staff failed to ensure 1 resident (Resident #122) of 63 residents in the survey sample received care in accordance with professional standards of practice. The facility staff failed to obtain an order for a stabilization/fracture boot which resulted in cellulitis to a surgical incision wound; and the facility staff inaccurately assessed and documented the cellulitis as a Stage 3 pressure ulcer. The findings included: Resident #122 was admitted on [DATE]. Diagnoses included but were not limited to, right tibial and fibular (lower leg) fracture and muscle weakness. Resident #122's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/03/2019 coded Resident #122 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #122 as requiring limited assistance of 1 for bed mobility, toilet use and personal hygiene, extensive assistance of 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 63 residents (Resident #164) in the survey sample who was unable to carry out activities of daily living, received the necessary services to maintain toenail care. The facility staff failed to ensure that podiatry services/nail care was provided to Resident #164. The findings included: Resident #164 was originally admitted to the facility on [DATE] with a readmission date of 03/05/19. Diagnoses for Resident #164 included but not limited to, Cerebral Infarction and heart failure. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 01/13/19 coded the resident on the Brief Interview for Mental Status as not able to complete the interview. Resident coded as having Short term and Long term memory problems. Indicating a moderate impairment for daily decision-making. Resident #164 was coded total dependence, two person physical assistance with personal…

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 clinical record review, the facility staff failed to ensure 1 of 63 residents in the survey sample, (Resident #78) was transferred according to the comprehensive care plan to prevent potential accidents. The facility staff failed to transfer Resident #78 with a mechanical lift per the resident's plan of care. The findings included: Resident #78 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Cerebral Palsy and Autistic Disorder. Resident #78's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 01/14/2019 coded Resident #78 with short-term memory problems, long-term memory problems and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #78 as requiring total dependence of 2 with transfers and total dependence of 1 for bed mobility, dressing, eating, toilet use, personal hygiene, bathing and locomotion on unit. On 06/10/2019 at 2:05 p.m., the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility staff failed to ensure one Resident (Resident #78) of 63 resident's in the survey sample, received appropriate treatment to prevent complications from enteral feeding. The facility staff failed to ensure safety precautions were followed to prevent potential complications from enteral feeding for Resident #78 during ADL (Activities of Daily Living) care. The findings included: Resident #78 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Cerebral Palsy and Autistic Disorder. Resident #78's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 01/14/2019 coded Resident #78 with short-term memory problems, long-term memory problems and with severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #78 as requiring total dependence of 2 with transfers and total dependence of 1 for bed mobility, dressing, eating, toilet use,…

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 interviews, clinical record review and facility documentation review the facility staff failed to communicate an ongoing assessment for one (Resident #421) of 63 residents in the survey sample, for monitoring of complications before after dialysis treatment. The facility staff failed to communicate an ongoing assessment with the dialysis center where Resident #421 attended outpatient dialysis three days per week every Monday, Wednesday and Friday. The findings included: Resident #421 was admitted to the facility on [DATE]. Diagnosis for Resident #421 included but not limited to *End Stage Renal Disease (ESRD) (Chronic irreversible kidney failure). The resident was receiving *hemodialysis treatments three times a week on Monday, Wednesday and Friday. The resident's Minimum Data Set (MDS) assessment was not due therefore no information was obtained from an MDS. The admission Assessment completed on 05/30/19 included the following: alert to person, place, time and situation 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 the facility's medication storage review/inspection of 4 medication carts and 2 medication rooms, the facility staff failed to dispose of Resident #471's medications after the resident was discharged , and failed to ensure accountability for controlled medications awaiting final disposition. The findings include: Resident #471 was admitted to the facility from an acute care facility with diagnoses that included but not limited to Diabetes mellitus, hyperlipidemia, and chronic pain. The resident was discharged on [DATE]. On [DATE] at approximately 10:56 AM an inspection was made in the medication storage room with Licensed Practical Nurse #6 (LPN). LPN #6 was not able to get into a locked cabinet that she stated that expired narcotics or medications were put. She said that the only staff members that have a key to the cabinet is the Director Of Nurses (DON). She was asked to have the DON unlock the cabinet for inspection. On [DATE] at approximately 11:09 AM the unit manager LPN #2 returned with the key…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility document review, it was determined that facility staff failed to maintain a complete and accurate clinical record for two of 17 residents in the survey sample, Residents #102 and #107. The findings include: 1. For Resident #102, facility staff failed to document any monitoring of her skin tear obtained on 7/27/19; and failed to document when her skin tear had healed. Resident #102 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to anemia, heart failure, high blood pressure, and diabetes. Resident #102's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/30/19. Resident #102 was coded as being intact in cognitive function scoring 15 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #102's nursing notes revealed that she had a fall on 7/27/19. The following nursing note 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 observations and staff interviews the facility staff failed to follow infection control practices therefore, increasing the chance of spreading infections, illnesses and diseases for 3 of 63 residents in the survey sample (Residents #39, 113, &104) and 7 dining room residents. 1. The Facility staff failed to perform hand hygiene before assisting 7 Residents during mealtime. 2. The facility staff failed to ensure Resident #39's indwelling catheter was managed in a manner to minimize the risk of cross-contamination and infections. 3. For Resident #113, facility staff failed to maintain his Foley catheter in a sanitary manner. 4. For Resident #104, facility staff failed to maintain respiratory equipment in a sanitary manner. The Findings Included; 1. On 06/07/19 at approximately 1:25 PM during a dining room observation in the Dayroom on unit two, three Certified Nursing Assistants (CNAs) were observed serving, feeding and assisting seven residents during mealtime without performing hand hygiene in between…

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, facility document review and staff interviews the facility staff failed to prepare, store, distribute and serve food in a safe, sanitary manner. The facility staff failed to ensure that the kitchen was free from pests to include roaches and drain flies, maintain a clean stove and oven that were free from copious amounts of grease and burnt debris, and ensure that an air gap was in place from the two food steamer units drain pipe to the floor drain. The findings included: On 9/6/17 at 7:55 a.m. during the initial kitchen tour the following observations were made: The two kitchen food steamer units were connected to one water drain pipe that was flush with and touching the floor drain. There was no visible air gap present. The six burner stove was noted to have large pieces of crusty burnt debris and a thick grease layer on and around all the burner. The three ovens were observed to have burnt/spillage debris on the oven floors and the oven racks were coated in thick black grease with raised areas of burnt food debris visible. One dead roach was observed on 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, facility document review and staff interviews the facility staff failed to maintain an effective pest control program to ensure the facility is free of pests. 1. The facility staff failed to ensure that the kitchen was free from pests to include roaches and drain flies. 2. The facility staff failed to ensure the facility was free from ants. The findings included: On 9/6/17 at 7:55 a.m. during the initial kitchen tour the following observations were made: One dead roach was observed on the floor between a three sink compartment unit and the pan drying rack. Also two live roaches were observed crawling on the floor in the main kitchen area under the sinks and crawling on the walls. In the dishwasher area five gray drain flies were observed crawling on the top and inside of the grease trap drain. On 9/6/17 at 8:15 a.m. an interview was conducted with the Dietary Aide. The Dietary Aide was asked if there are issues with roaches and pests in the kitchen. The Dietary Aide stated, We have them every now and then. The bug man comes in and sprays. On 7/6/17 at 11:30…

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 documentation review, clinical record review, and the facility staff failed to assess one of 26 Residents in the survey sample (Resident #15) ability to self administer Voltaren Gel. The findings included: Resident #15 was admitted to the facility on [DATE]. Diagnoses for Resident #15 included but are not limited to Chronic Pain. Resident #15's Quarterly Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 5/28/17, coded Resident #15 with a BIMS (Brief Interview for Mental Status) of 15 of 15 indicating no cognitive impairment. In addition, the Quarterly MDS coded Resident #15 as being independent in Dressing, Eating, Toilet use and Hygiene. Resident #15 was coded as not being observed ambulating and having a wheel chair and walker as mobility devices. On 9/6/17 at approximately 9:45 a.m., an observation was made of Resident #15 sitting on her bed with a tube of Voltaren* Gel lying on the bed beside her. On 9/7/17…

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, clinical record review, and review of the facility's policy the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for one of 26 residents (Resident #17), in the survey sample. The facility staff failed to code Resident #17's MDS assessment correctly at section A1500 through A1550. The findings included: Resident #17 was originally admitted to the facility 10/15/1998 and readmitted [DATE] after an acute illness resulting in hospitalization. The current diagnoses included; a developmental disorder, cerebral palsy, an autistic disorder and mental retardation (MR). The quarterly MDS assessment with an assessment reference date (ARD) of 7/14/17 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 daily decision making abilities. The resident was also coded as having no speech, rarely to never…

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 interviews, facility documentation review and clinical record review the facility staff failed to update a comprehensive person centered care plan after a fall for one of 26 residents (Resident #10) in the survey sample. The facility staff failed to revise Resident #10's comprehensive care plan to include a fall on 02/12/17. The findings included: Resident #10 was originally admitted to the facility on [DATE]. Diagnosis for Resident #10 included but not limited to muscle weakness (1) and Alzheimer's (2). The current Minimum Data Set (MDS), a comprehensive assessment with an Assessment Reference Date (ARD) of 08/15/17 coded the resident with a 6 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. In addition, the MDS coded Resident #10 with extensive assistance of two with bed mobility, dressing, toilet use and personal hygiene and extensive assistance of one with bathing. The comprehensive care plan was reviewed on 12/12/16; the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and facility documentation review the facility staff failed to date two open multidose vials of insulin for 2 out of 26 residents (Resident #19 and Resident #20) in the survey sample. 1. The facility staff failed to date an opened multidose vial of Novolog (1) insulin (Resident #19). 2. The facility staff failed to date an opened multidose vial of Humalog (2) insulin (Resident #20). The findings included: 1. Resident #19 was originally admitted to the facility on [DATE] with diagnosis to include but not limited to Type 2 Diabetes Mellitus (3) (DM). The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 08/19/17 coded the resident with a score of 99 indicating severely impaired with daily decision making. On 09/7/17 at 9:10 a.m., during inspection of the medication room on Unit 1, located in the medication refrigerator was one unlabeled multidose vial of Novolog insulin. The surveyor asked LPN #1, when was the insulin opened, she…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and facility documentation the facility staff failed to ensure labs were obtained as ordered for one out of 26 residents (Resident #1) in the survey sample. The facility staff failed to ensure labs were obtained as ordered for the following: Basic Metabolic Panel (BMP) (1) and Hemoglobin A1C (2) for the month of August 2017. The findings included: Resident #1 was originally admitted to the facility on [DATE]. Diagnosis for Resident #1 included but not limited to Type 2 Diabetes Mellitus (3) and Heart Failure (4). Resident #1's most recent MDS assessment was a comprehensive assessment with an ARD of 5/31/17. The Resident was coded with a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15, indicating no cognitive impairment. In addition, the MDS coded Resident #1 requiring total dependence of one with bathing, extensive assistance of two with transfers, extensive assistance of one with bed mobility, dressing, toilet use and personal hygiene.…

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 accurately document medical record information for one of 26 residents (Resident #17), in the survey sample. The facility staff failed to accurately document information on Resident #17's Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions assessments. The findings included: Resident #17 was originally admitted to the facility 10/15/1998 and readmitted [DATE] after an acute illness resulting in hospitalization. The current diagnoses included; a developmental disorder, cerebral palsy, an autistic disorder and mental retardation (MR). The quarterly MDS assessment with an assessment reference date (ARD) of 7/14/17 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 daily decision making abilities. The resident was also coded as having no speech,…

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.