Deep Creek Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews and facility document review the facility failed to ensure that 10 of 56 residents in the survey sample were afforded the opportunity to formulate an Advance Directive upon admission, Residents' #52, #257, #258, #255, #26, #57, #48, #7, #25 and #94. The findings included: 1. Resident #52 was admitted to the facility initially on 8/12/20 and readmitted on [DATE] with diagnoses to include but not limited to Diabetes Mellitus, Hypertension and Major Depressive Disorder. Resident #52's most recent MDS (Minimum Data Set) was a Quarterly with an ARD (Assessment Reference Date) of 6/4/21. Resident #52's BIMS (Brief Interview for Mental Status) was coded as a 7 out of a possible 15 indicating the resident was moderately cognitively impaired but capable of some daily decision making. Resident #52's Physician Progress Note dated 7/7/21 was reviewed and is documented in part, as follows: Care Plan: Recommendations: Code Status-Full Code Resident #52's Comprehensive Care Plan…

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

Based on clinical record review and staff interviews, the facility's staff failed to complete a quarterly Minimum Data Set (MDS) assessment at least every 92 days for each resident. The findings included; During the course of the survey 7/20/21 through 7/22/21 many residents reviewed didn't have a current MDS assessment in the clinical record. Twenty residents were included in the survey for investigations. Eight of the twenty were missing a quarterly review and two of the twenty had missing annual MDS assessments. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. (CMS Resident Assessment Instrument Version 3.0 Manual, dated October 2019, Chapter 2, page 2-33) On 7/20/21 at approximately 4:10 p.m., the Director of Nursing was asked to identify the MDS Coordinator and she stated the MDS Coordinator…

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

Based on clinical record review and staff interviews, the facility's staff failed to complete the resident required discharge Minimum Data Set (MDS) assessment within the required timeframe after each discharge from the facility. The findings included; On 7/20/21 at the end of the day meeting, a review of all offsite selected residents was conducted. CMS had identified 12 residents. Of the 12 residents six had been discharged from the facility, four had been discharged for more than 28 calendar days yet the discharge MDS assessment wasn't included in the clinical record or transmitted to CMS. CMS's Resident Assessment Instrument Version 3.0 Manual, dated October 2019, Chapter 2, page 2-37 instructions read; a discharge MDS assessment must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days) and the assessment must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). On 7/20/21 at approximately 4:10 p.m., the Director of Nursing was asked to identify the MDS Coordinator and she stated the MDS Coordinator…

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

Based on review of facility documents and staff interview, the facility's staff failed to ensure a Registered Nurse was on duty for 8 consecutive hours each day The findings included: During review of staffing it was identified that a Registered Nurse (RN) had not worked at least 8 consecutive hours a day, 7 days a week over a six month timespan. The deficits were on the weekends and major holidays. An interview was conducted with the previous staffing coordinator. After a careful review of the schedules she concluded the RN coverage wasn't available 8 consecutive hours a day, 7 days a week. On 7/22/21 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Clinical Specialist. The Clinical Specialist stated she wasn't aware of the RN staffing concerns. The Director of Nursing stated that was in the past but the review revealed as recent as 7/11/21 and 7/17/21, a RN didn't work 8 consecutive hours.

Based on observations, clinical record review, and staff interview, the facility's staff failed to maintain a resident's dignity by ensuring the bedside drainage bag fluid was concealed from view for 1 of 56 residents (Resident #14), in the survey sample. The findings included: Resident #14 was originally admitted to the facility 12/11/18 and has never been discharged from the facility. The current diagnoses included; Multiple Sclerosis and neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/11/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility and transfers, total care of one person with dressing, toileting, personal hygiene and bathing, and supervision after set-up with eating. In section H (Bladder and Bowel) the resident was coded at H0100 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 information obtained during the Resident Council Meeting, and interviews, the facility staff failed to inform residents of the location of the survey book which listed the results of the most recent surveys. The findings included: A resident council meeting was held in the resident dining hall on 7/21/21 at approximately, 11:00 AM. Six residents attended the meeting. The residents stated they were not aware of the location of the survey results book or were not aware they could see the results of past surveys conducted . Upon inspection of the survey results book it was determined that the most recent complaint survey results were not posted in the survey book. The last survey posted in the survey book was dated 12/23/2019. According to the Office of Licensure and Certification complaint surveys were conducted on the following dates: 12/12/20, 2/12/21 and 4/15/21. These surveys should have been posted in the survey book for residents, family members and legal representatives to view. On 7/21/21 at approximately 11:45 AM an interview was conducted with the Activity Director…

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

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #34 and Resident 55) in the survey sample. The findings included: 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #34 who was discharged from skilled services with Medicare days remaining. Resident #34 was originally admitted to the nursing facility on 03/17/21. Diagnosis for Resident #34 included but not limited to Congestive Heart Failure (CHF). Resident #34's Minimum Data Set (MDS) an OBRA quarterly assessment with an Assessment Reference Date (ARD) date of 03/22/21 coded Resident #34 a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated moderate cognitive impairment. Review of the SNF Beneficiary Notification Review provided by the facility to surveyor, was noted that Resident #34 was not listed for having been issued the SNF ABN (Skilled Nursing Facility-Advanced…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to ensure all the required documentation including care plan goals and physician/RP (responsible party) contact information were sent with one of 56 residents; Resident #48 upon transfer to the hospital on 1/19/21. The findings included: Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, diabetes mellitus, high cholesterol, Alzheimer's disease, and dementia. Resident #48's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 4/2/21. Resident #48 was coded as being severely impaired in cognitive function scoring 00 out of 15 on the BIMS (Brief Interview for Mental Status Exam). Review of Resident #48's clinical record revealed that she was sent out to the hospital on 1/19/21. The following nursing note was documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to notify the local long term care ombudsman of an acute care transfer to the hospital for two of 56 sampled residents; Resident #48 and #52. The findings included: 1. Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, diabetes mellitus, high cholesterol, Alzheimer's disease, and dementia. Resident #48's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 4/2/21. Resident #48 was coded as being severely impaired in cognitive function scoring 00 out of 15 on the BIMS (Brief Interview for Mental Status Exam). Review of Resident #48's clinical record revealed that she was sent out to the hospital on 1/19/21. The following nursing note was documented in part: During nursing rounds, this writer noted that resident 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, facility document review and clinical record review, it was determined that facility staff failed to ensure the written bed hold policy was sent with one of 56 residents; Resident #48 upon transfer to the hospital on 1/19/21. The findings included: Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, diabetes mellitus, high cholesterol, Alzheimer's disease, and dementia. Resident #48's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 4/2/21. Resident #48 was coded as being severely impaired in cognitive function scoring 00 out of 15 on the BIMS (Brief Interview for Mental Status Exam). Review of Resident #48's clinical record revealed that she was sent out to the hospital on 1/19/21. The following nursing note was documented in part: During nursing rounds, this writer noted that resident was sweating…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to complete a significant change MDS (Minimum Data Set) assessment for one of 56 residents; Resident #41, after being admitted to hospice services. The findings included: Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure, high blood pressure, diabetes mellitus, high cholesterol, Alzheimer's disease, and dementia. Resident #48's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 4/2/21. Resident #48 was coded as being severely impaired in cognitive function scoring 00 out of 15 on the BIMS (Brief Interview for Mental Status Exam). Review of Resident #48's clinical record revealed that he was put on hospice services on 6/17/21. The following current order was documented: admission to receive hospice services from (Name of Hospice…

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 the facility staff failed to inform one resident representative of care plan meetings and follow ups after conducting CP meetings. The findings included: Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to End Stage Renal Disease and Major Depressive Disorder. Resident #7's most recent MDS (Minimum Data Set Assessment) was a quarterly revision assessment with an ARD (assessment reference date) of 03/03/21. Resident #7 was coded as scoring 5 out of possible 15 on the BIMS (Brief Interview for Mental Status exam). This indicated Resident #7's cognitive abilities for daily decision making were severely impaired. On 7/21/21 at approximately, 9:09 A.M., an interview was conducted with Resident #7 during the initial tour. She could not recall receiving a recent invitation for a care plan meeting. Resident #7 stated, What…

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 the facility staff failed to complete weekly wound assessments for a pressure ulcer* to the right heel that was present upon admission for one of 56 sampled residents, Resident #57. *Pressure Injury (ulcer)- A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. https://npuap.org/page/PressureInjuryStages. The findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Anemia, atrial fibrillation, renal…

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

Based on observation, staff interview, and clinical record review, the facility's staff failed to ensure the resident's call bell was kept within reach for 1 of 56 residents (Resident #39), in the survey sample. The findings included: Resident #39 was originally admitted to the facility 5/2/15 and has never been discharged from the facility. The current diagnoses included; schizophrenia and a psychotic disorder. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/22/21 coded the resident as not completing the Brief Interview for Mental Status (BIMS) therefore a staff interview was conducted. It revealed the resident recalls the season, staff names and faces, room location and that he is in a nursing home. The conclusion was with modified independence decision making in new situations. In section G (Physical functioning) the resident was coded as requiring total care with bathing, extensive assistance of one person with personal hygiene and bathing, limited assistance with transfers and toileting and supervision after set-up with eating. 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 observation, staff interview and facility document review, it was determined that facility staff failed to appropriately store medications on one of four facility medication carts; the 400 hall medication cart. The findings included: On 7/21/21 at 11:56 a.m., observation of the 400 hall medication cart was conducted. The top drawer to the medication cart had a medication cup full of eight pills that were unidentified. When asked the nurse (LPN (Licensed Practical Nurse) #3 who the pills belonged to, LPN #3 stated that the pills belonged to a resident who didn't want to take them right away at 9 a.m. LPN #3 stated that this resident wanted her to leave the pills in his room but that she didn't think that was appropriate. LPN #3 stated that she left the pills in the top drawer because she as going to attempt to give him his medication later. When asked if his medication should have been discarded at the time of refusal,. LPN #3 stated, Yes. LPN #3 stated that she shouldn't have left the cup of pills in the first drawer of the medication cart. On 7/22/21 at approximately 4:30…

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.

Based on observation and staff interview, the facility staff failed to ensure that the garbage disposal area was free from garbage and refuse. The findings included: On 07/20/21 at approximately 11:40 a.m., a tour of the outside dumpster area was made with the Dietary Manager. Four dumpsters were observed outside in the dumpster area. The smallest dumpster observed with the following: The bottom of the dumpster was coming apart with used briefs, used gloves, trash coming from the opening (front and back of the dumpster). Surrounding the dumpster on the ground (front and back) were used gloves, used briefs, paper, plastic bottles and food. Flies and nets were observed flying around the garbage and refuse that was coming from the bottom of dumpster where it was coming apart. Behind the dumpster was the following: 3 old ripped/torn mattresses with standing water on the top mattress and trash scattered all over the back area near the fence. The Dietary Manager was asked, Who is responsible for ensuring the dumpster area is free from garbage and refuse, she replied, I must be honest, I…

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

Based on review of facility documents and staff interviews, the facility's staff failed to ensure two of two Certified Nurse Aides (CNA) in-service training included dementia management and resident abuse prevention training. The findings included; A review was conducted on two CNA's training program. The training records didn't include dementia management and resident abuse prevention training. On 7/21/21 at approximately 11:40 a.m., an interview was conducted with CNA #1. CNA #1 stated she had received training in working with dementia residents and she was capable of stating best practice information regarding working with resident's with dementia with or without behaviors. CNA #1 was also capable of stating some types of abuse and what to do if a resident was not compliant with care. An observation was made on 7/21/21 as CNA #1 provided care to a resident with dementia and behaviors. No concerns were observed. CNA #1 stated education is always welcomed. On 7/22/21 at approximately 4:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to evidence that all the required documentation (including care plan goals) was sent with the resident during a facility-initiated transfer to the hospital for 5 of 44 residents in the survey sample, Resident #21, 31, 22, 35, 41. 1. For Resident #21, facility staff failed to evidence that care plan goals were sent with the resident during a transfer to the hospital on 1/13/19. 2. For Resident #31, facility staff failed to evidence that care plan goals were sent with the resident during a transfer to the hospital on 1/18/19. 3. For Resident #22, facility staff failed to evidence that care plan goals were sent with the resident during a transfer to the hospital on 3/4/19. 4. The facility staff failed to convey to the receiving provider, Resident #35's Plan of Care Summary upon transfer to the hospital 12/18/18. 5. The facility staff failed to send care plan goals upon Resident #41's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written documentation that the ombudsman was notified of a resident transfer for 8 of 44 residents in the survey sample, Resident #21, #31, #22, 35, 41, 17, 57, and 103. 1. For Resident #21, facility staff failed to provide written documentation that the Office of the State Long-Term Care Ombudsman was notified of her transfer to the hospital on 1/13/19. 2. For Resident #31, facility staff failed to provide written documentation that the Office of the State Long-Term Care Ombudsman was notified of his transfer to the hospital on 1/18/19. 3. For Resident #22, facility staff failed to provide written documentation that the Office of the State Long-Term Care Ombudsman was notified of his transfer to the hospital on 3/4/19. 4. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #35's transfer to the local acute care hospital 12/18/18. 5.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written notification of the bed hold policy at the time of a facility-initiated transfer for 8 of 44 residents in the survey sample, Resident #21, 31, 22, , 35, 41, 17, 57, and 103. 1. The facility staff failed to provide Resident #21 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on 1/13/19. 2. The facility staff failed to provide Resident #31 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on 1/18/19. 3. The facility staff failed to provide Resident #22 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on 3/4/19. 4. The facility failed to provide Resident #35 with a written notice of the facility's Bed-Hold Policy upon transfer to the hospital…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #104 was admitted to the facility on [DATE] with diagnoses of schizophrenia, diabetes mellitus, Non-Alzheimer's Dementia, hemiplegia and seizure disorder. The facility staff failed to provide a (Preadmission Screening and Resident Review) (PASARR) to assess the need of Resident #104 for a mental disorder or intellectual disability prior to admission. An Initial Minimum Data Set (MDS) dated [DATE] assessed Resident #104 in the area of hearing, speech and vision as having no difficulty's. In the area of Cognitive Patterns this resident had a BIMS score of 3. In the area of Functional Status Activities of Daily Living (ADL'S) this resident was assessed in the areas of bed mobility, transfer, dressing, eating toilet use and personal hygiene as requiring extensive assistance of one person physical assist. A Care Plan dated 3/19/19 indicated: Problem/Need- Resident #104 has little or no activity involvement r/t new admit to facility needs time for adjustment. Resident has history of schizophrenia. Goal-…

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

Based on staff interviews and facility documentation review, the facility staff failed to staff a Registered Nurse (RN) for at least 8 hours a day, 7 days a week and failed to ensure the Director of Nursing (DON) worked as a supervisor/charge nurse only when the facility had a census of 60 or less. The findings included: A review of the as work schedules from October 2018 through April 14, 2019, were reviewed which resulted in further review of the RN weekend coverage. The review concluded there was no RN coverage for at least 8 consecutive hours and the DON worked as a supervisor/charge nurse when the facility had a census of more than 60 residents on the following days: 1. Sunday, October 7, 2018, the scheduled RN called out, there was a RN in the facility but she was on orientation. She worked 5.5 hours (9:45 a.m.-3.15 p.m.). 2. Saturday, October 20, 2018, the Director of Nursing (DON) worked as the supervisor/charge nurse. She worked 5.5 hours (10:45 a.m.-4:15 p.m.) with a facility census of 108. 3. Sunday, October 21, 2018, the Director of Nursing (DON) worked as the…

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

Based on clinical record review, staff interviews, and review of the facility's policy the facility staff failed to meet the needs of the residents by collecting specimens and obtain laboratory services for 1 of 44 residents (Resident #51), in the survey sample. The facility staff failed to obtain Resident #51's monthly complete blood count ordered 6/4/18, and the facility staff failed to obtain a complete metabolic panel, thyroid stimulating hormone, hemoglobin A1C levels, magnesium, uric acid, and a lipid profile ordered every April, August and December beginning 6/4/18. The findings included: Resident #51 was originally admitted to the facility 6/29/15 and the resident has never been discharged from the facility. The current diagnoses include; stroke with hemiparesis, renal insufficiency and anemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/15/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicates Resident #51's cognitive abilities for daily decision…

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

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 discharged residents (Resident #38 and #94) in the survey sample. 1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #38 who was discharged from skilled services with Medicare days remaining. 2. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #94 who was discharged from skilled services with Medicare days remaining. The findings included: 1. Resident #38 was re-admitted to the nursing facility on 12/06/18. Diagnosis for Resident #38 included but not limited to Muscle Weakness. Resident #38's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/14/19 coded Resident #38 a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) that indicated no cognitive impairment. On review of the Beneficiary Notification Checklist provided by 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 observations, clinical record review, staff interviews, and review of the facility's policy the facility staff failed to assure Minimum Data Set (MDS) assessments accurately reflected the resident's status at the time of the assessment for 2 of 44 residents (Resident #11 and #41), in the survey sample. 1. The facility staff failed to assure Resident #11's 1/14/19, quarterly MDS assessment was accurately coded at section P0100 (Physical Restraints). 2. The facility staff failed to ensure that Resident #41's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/19 was accurately coded under Section P (Restraints and Alarms). The findings included: 1. Resident #11 was originally admitted to the facility 3/12/15 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; intellectual disability, right hemiparesis and cerebral palsy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/14/19, coded the resident 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 Based on record review, individual and staff interviews the facility staff failed to develop a care plan for seizures for one resident (Resident #27) in the survey sample of 44 residents. The findings included: Resident #27 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included seizures, depression, anxiety, bipolar disorder, hypertension, contractures of left hand, COPD, hypokalemia, dementia and cardiovascular disease. The facility staff failed to care plan seizure activity for Resident #27. A Quarterly Minimum Data Set, dated [DATE] assessed this resident in the area of Hearing, Speech, and Vision as makes himself understood and usually understands. This resident was assessed as having impaired vision. In the area of Cognitive Patterns this resident was assessed as scoring a 12 on the Brief Interview for Mental Status. In the area of Behavior this resident was assessed as having behaviors directed towards others, verbal behaviors directed towards other, and other…

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 complaint investigations, staff interviews, facility document review, and clinical record review the facility staff failed to ensure that one (1) of 44 residents in the survey sample received treatment and care in accordance with professional standards of practice, Resident # 22. The facility staff failed to administer five consecutive doses of scheduled Ativan. The findings included: Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to anxiety disorder, hyponatremia (low sodium), severe panic disorder, muscle weakness, Hepatitis C, protein-calorie malnutrition and diabetes (type two). Resident #22's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date of 1/31/19. Resident #22 was coded as being moderately impaired in cognitive function scoring 11 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #22's clinical record revealed 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 a complaint investigation, clinical record review, facility document review and staff interviews the facility staff failed to ensure timely physician orders for the care of multiple pressure ulcers were obtained for 1 of 44 residents in the survey sample, Resident #106. The facility staff failed to obtain physician orders for the care of multiple pressure ulcers upon admission for Resident #106 within a timely manner. The findings included: Resident #106 was admitted to the facility on [DATE] with diagnoses to include but not limited to Decubitus Ulcer of the sacral region, Malnutrition and Alcohol Abuse. The most recent Minimum Data Set (MDS) assessment was an admission 5/Day with an Assessment Reference Date (ARD) of 6/25/18. The Brief Interview for Mental Status was a 15 out of a possible 15 indicating Resident #106 was cognitively intact and capable of daily decision making. Under Section M Skin Conditions, Resident #106 was coded to have 2 Stage II, 4 Stage III, and 2 Stage IV pressure areas…

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 a complaint investigation, facility record review, staff interviews, resident interviews and facility document review the facility staff failed ensure 2 of 44 residents in the survey sample received their diabetic shoes in a timely manner, Resident #17 and Resident #24. 1. The facility staff failed to ensure a pair of diabetic shoes was provided to Resident #24 in a timely manner. 2. The facility staff failed to provide Resident #17 with physician ordered diabetic shoes. The findings included: 1. Resident #24 was a [AGE] year old admitted to the facility on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus and Peripheral Vascular Disease. The most recent Minimum Data Set was an Annual assessment with an Assessment Reference Date of 1/21/19. The Brief Interview for Mental Status was a 12 out of a possible 15 indicating Resident #24 was cognitively intact and capable of daily decision making. Resident #24's Telephone Physician Order dated 3/7/18 was reviewed and is documented 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and a complaint investigation, the facility staff failed to adequately assess and obtain pain medication for one resident (Resident #57) in the survey sample of 44 residents. The findings included: Resident #57 was re-admitted to the facility on [DATE] with diagnoses which included a history of sepsis due to Escherichia coli (E.Coli) esophagitis, muscle weakness, dysphagia, abnormalities of gait, hypertension, COPD, depression, diabetes, cardiovascular disease, hyperlipidemia, and contracture of left hand. The facility staff failed to provide routine pain medications to Resident #57. A Re-entry Minimum Data Set (MDS) dated [DATE] assessed this resident as having no difficulties in the area of hearing, speech, vision or understanding and the ability to be understood. In the area of Cognitive Patterns this resident was assessed for a brief Interview for mental Status (BIMS) and scored a (13). This resident was assessed in the area of Activities of Daily Living (ADL'S) 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 Based on record review, staff interview and a complaint investigation, the facility staff failed to have available pain medication to one resident (Resident #57) in the survey sample of 44 residents. The findings included: Resident #57 was re-admitted to the facility on [DATE] with diagnoses which included a history of sepsis due to Escherichia coli (E.Coli) esophagitis, muscle weakness, dysphagia, abnormalities of gait, hypertension, COPD, depression, diabetes, cardiovascular disease, hyperlipidemia, and contractures of left hand. The facility staff failed to have routine pain medications available to Resident #57. A Re-entry Minimum Data Set (MDS) dated [DATE] assessed this resident as having no difficulties in the area of hearing, speech, vision or understanding and the ability to be understood. In the area of Cognitive Patterns this resident was assessed for a brief Interview for mental Status (BIMS) and scored a (13). This resident was assessed in the area of Activities of Daily Living (ADL'S) as 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 observation, resident interview, staff interviews, clinical record review, and review of the facility's policy, the facility staff failed to provide an assistive eating device to a resident who needed it to improve their ability to eat independently for 1 of 44 residents (Resident #11), in the survey sample. The facility staff failed to provide Resident #11 with the ordered Rocker knife during the midday meal on 4/11/19 and 4/12/19. The findings included: Resident #11 was originally admitted to the facility 3/12/15 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included intellectual disability, right hemiparesis and cerebral palsy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/14/19, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #11's cognitive abilities for daily decision making are intact. In section G (Physical functioning) 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, facility document review, and clinical record review, it was determined that facility staff failed to maintain infection control practices during wound care observation for one of 44 residents in the survey sample, Resident #79. For Resident #79, facility staff failed to maintain infection control practices during wound care observation of his right heel pressure ulcer (1). (1) A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Most frequently seen in elderly and immobilized persons, decubitus ulcers may be prevented by frequently change of position, early ambulation, cleanliness, and use of skin lubricants and a water or air mattress. Also called bedsores. Pressure sores. Barron ' s Dictionary of Medical Terms for the Non Medical Reader 2006; [NAME] A. Rothenberg, M.D. and [NAME] F. [NAME]. Page 155. 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.