Health Care Center Lucy Corr

Based on record review, resident interview, staff interview, the facility failed to ensure routine dental services were offered to one of one Resident (R)26 reviewed for dental services. Findings include: Review of R26's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/03/23 indicated that R26 had a Brief Interview for Mental Status (BIMS) of 14 out of 15, indicating the resident was cognitively intact. During an interview on 02/02/23 at 10:10 AM, R26 stated that she knew she needed dental work or dentures but was unsure if she could get an appointment with a dentist. She revealed she had been at the facility for two years and has not had seen a dentist. Review of R26's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date in February 2021. During an interview on 02/03/23 at 2:00 PM with the Social Services Director, Staff D, who is responsible for arranging resident dental appointments, with the in house free dental clinic stated, We do not automatically get everyone a dental appointment, unless their family…

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

Based on staff interview and facility documentation review, the facility staff failed to ensure Committee Members were present for QAPI meetings for 4 of 4 QAPI meetings. The Findings included: For the QAPI meetings, the facility staff failed to ensure core members were present for each meeting. On 02/06/23 at 2:56 p.m., Meeting with DON and Administrator- Administrator stated the QAA, QAPI meets quarterly, The dates of the meetings in the past year were 11/15/2022, 8/31/2022, 5/18/2022 and 2/9/2022. Those in attendance were: 11/15/2022- The Administrator, Director of Nursing, Medical Director and 3 LPNs. (the Infection Preventionist was not present) 8/31/2022- The Administrator, Director of Nursing, Medical Director and 1 LPN. (the Infection Preventionist was not present and 1 other facility staff was not present) 5/18/2022- There were no signatures. All names were printed in the same penmanship. There were 3 listed on the top section as Healthcare Center Advisory Members on Web-ex. The bottom section listed 6 printed names including the Administrator, Director of Nursing, Chief…

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, resident interview, and facility documentation review the facility staff failed to provide a dignified dining experience in 1 of 6 dining rooms (involving multiple residents) and for two Residents (Resident #29, Resident #82) in a survey sample of 60 Residents. 1. The facility staff failed to serve meals to all residents at the same table, at the same time, in 1 of 6 dining rooms. 2. For Resident #29, the facility staff stood over resident while feeding and after feeding the resident three bites, left to go assist a different resident . 3. For Resident #82, the facility staff failed to serve meals at the same time as her table mates. The findings included: 1. The facility staff failed to serve meals to all residents at the same table, at the same time in 1 of 6 dining rooms. On 4/28/19 at 6:00pm during observation of the meal in the Midlothian dining room it was observed that there were 7 tables in the dining room and 26 residents were present, for the meal. The first plate…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to develop comprehensive, resident-centered care plans for 6 residents (Resident #146, Resident #14, #105, #180, #49, and #192) in a sample of 60 residents. 1. For Resident #146, the facility staff failed to complete a comprehensive care plan for bathing & foley catheter care. 2. For Resident #14, the facility staff failed to complete a comprehensive care plan for contracture care. 3. For Resident #105, the facility staff identified the resident was at high risk for falls on 2/15/19 and failed to develop a comprehensive careplan to include interventions to prevent falls until 3/21/19. 4. For Resident #180 the facility failed to adequately identify specific inappropriate behavior being care planned in order to monitor measure and evaluate for effectiveness. 5. For Resident # 49 the facility failed to address Oxygen use in her care plan. 6. For Resident #192, 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, resident interview, facility documentation review, and clinical record review, the facility staff failed to provide adequate ADL (activities of daily living) care for four residents (Resident #146, #14, #86, and Resident #51) in the survey sample of 60 Residents. 1. For Resident #146, the facility staff failed to provide adequate fingernail and incontinence care. 2. For Resident #14, the facility staff failed to provide adequate nail care, and skin care. 3. For Resident #86, the facility staff failed to provide assistance with eating. 4. For Resident #51, the facility staff failed to provide timely assistance with ADL's (Activities of Daily Living) and in accordance with plan of care. The Findings included: 1. For Resident #146, the facility staff failed to provide adequate fingernail and incontinence care. Resident #146 was admitted to the facility on [DATE]. Diagnoses included; Congestive heart failure, urine retention, foley catheter, dysphagia, atrial fibrillation, muscle weakness, 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 3. For Resident #251, the facility failed to ensure that she was free of a malfunctioning wheelchair - related accident hazard. Resident #251 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #251's diagnoses included Anxiety Disorder, Dementia, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Gout, Heart Failure, and Age-related Nuclear Cataract - Bilateral. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/1/19 was reviewed. Resident #251 was coded as having a Brief Interview of Mental Status Score of 9, indicating moderately impaired cognition. Resident #251 was also coded as having impaired vision. In addition, she was coded as being independent in locomotion with a wheelchair. On 4/28/19 at approximately 4:00 P.M., an interview was conducted with Resident #251 at the nurse's station. Resident #251 stated, my wheelchair is shaky I may fall out, it's not safe. It rubs against the wheel. She noted that it was difficult to propel 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, clinical record review, and facility documentation review the facility staff failed to ensure four Resident's (Resident #84, Resident #28, Resident #452, and Resident #113) received oxygen as ordered, in a survey sample of 60 Residents 1. For Resident #84, the facility staff failed to ensure that physician ordered continuous oxygen was administered in accordance with the plan of care. 2. For Resident #28, the facility staff failed to provide continuous oxygen treatment as ordered by the physician. 3. For Resident #452, the facility staff failed to ensure she received continuous oxygen therapy. 4. For Resident #113, the facility staff failed to ensure that physician ordered continuous oxygen was administered in accordance with the plan of care. The findings included: 1. For Resident #84, the facility staff failed to ensure that physician ordered continuous oxygen was administered in accordance with the plan of care. Resident #84 was admitted to the facility on [DATE].…

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 documentation and clinical record review the facility staff failed to ensure sufficient staff for adequate care. 1. The facility staff failed to provide sufficient staff to answer calls bells in a timely manner. 2. The facility staff failed to provide sufficient staff to feed Residents in timely manner. 3. For Resident #146, the facility failed to provide sufficient staff to maintain bathing and hygiene cleanliness. The findings include: 1. The facility staff failed to provide sufficient staff to answer calls bells in a timely manner. On 04/29/2019 at approximately 10:55 AM, Surveyor E interviewed Resident #174. When asked if staff overall answers call bell promptly, Resident #174 stated It takes a long time to get any help and From 3-11 is a problem. Resident #174 stated that in the evenings, he needs help getting transferred into bed, getting his bed clothes on, and getting off the toilet. On 4/29/19 at 10:40 A.M., Surveyor A conducted a private group…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to properly store medication and the facility staff failed to provide a separately locked, permanently affixed compartments for storage of controlled drugs in three of five medication rooms. 1. Fluticasone for Resident #81 and Humalog for Resident #170 were sitting out on top of Medication Cart #1 on the Midlothian unit unsupervised. 2. In three of five medication rooms the facility staff failed to provide a separately locked, permanently affixed compartment for storage of refrigerated controlled drugs. The findings included: 1. Fluticasone for Resident #81 and Humalog for Resident #170 were sitting out on top of Medication Cart #1 on the Midlothian unit unsupervised. On 04/29/2019 at 10:42 AM, this surveyor and Surveyor C observed a bottle of fluticasone and a vial of Humalog insulin on the top of Cart 1 unsupervised. The cart was up against the wall in the hall of the Midlothian unit near resident rooms. Within one minute of this observation, LPN J approached the med cart. When…

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 and staff interviews, the facility staff failed to assign staff with appropriate skill set to effectively carry out the functions of food and nutrition services. The facility staff assigned a dietary aide to the 3-compartment sink before he received the training and competencies to do so. The findings included: On 04/29/2019 at approximately 10:15 AM, this surveyor requested to observe a check of the three compartment sink. Employee D was washing pots at the first sink. There were three pots in the three compartment sink. Employee H walked up to the three compartment sink and removed the pots and returned them to the first compartment. When asked why he removed the pots from the third compartment, he stated, Because they had soap on them. It was noted at that time that Employee H also drained all the solution out of the three compartment sink and began to refill it. When this surveyor asked why he emptied the sink when we were going there to test it, he stated, Sorry about that. When asked who was responsible for preparing the three compartment sink, he stated…

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

Based on observation, staff interview, and facility documentation, the facility staff failed to follow proper sanitation practices facility-wide and failed to serve food with proper sanitation practices and at proper holding temperature in one of six dining rooms. 1. A facility staff member held a pen and the thermometer in her gloved hand simultaneously while temping the pureed eggs, the pureed sausage, and the sausage gravy. The pen hovered over the food and touched the edges of the food container at times during the temping process. 2. According to the facility's sanitizer solution log, the three compartment sink was not tested for three days in April to ensure the pots were effectively sanitized and chemical contamination was avoided. 3. The facility staff failed to perform proper hand washing prior to meal service. 4. The facility staff failed to serve food in a sanitary manner in the Midlothian dining room. 5. The facility staff failed to label and date food stored in the fridge in the Midlothian kitchenette. The findings included: 1. A facility staff member held a pen and the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain accurate and readily accessible medical records for four residents (Resident #198, Resident #179, Resident #452, Resident #105) in a sample size of 60 residents. 1. For Resident #198, the social worker did not document social services notes in the clinical record but kept notes in a soft file in her office. 2. For Resident #179, the social worker did not document social services notes in the clinical record but kept notes in a soft file in her office. There are inconsistencies in the bowel and bladder status documentation and the bowel and bladder elimination record is incomplete. 3. For Resident #452, there was no physician's order for oxygen but the Medication Administration Record listed oxygen at 2 liters per minute continuous and the sign-off as administered was incomplete. 4. For Resident #105, the facility staff failed to accurately code a Morse Fall Scale/Risk…

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, facility documentation review, and clinical record review, the facility staff failed to assess if a resident was safe to self administer medications for one Resident (Resident #149), in a survey sample of 60 Residents. For Resident #149, the facility staff failed to assess if the resident was safe to self administer prescription medications kept at the bedside. The findings included: Resident #149, was admitted to the facility on [DATE]. Resident #149 diagnoses included, but were not limited to: paroxysmal atrial fibrillation, malignant neoplasm of prostate, secondary malignant neoplasm of bone, hypertension anxiety disorder, and hearing loss. Resident #149's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4/1/19, was coded as a quarterly assessment. Resident #149 was coded as not being able to be assessed for a BIMS (brief interview for mental status) and staff indicated the resident was severely cognitively impaired. Resident #149 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 2. For Resident #251, the facility staff failed to accommodate her need for an appropriate wheelchair. Resident #251 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #251's diagnoses included Anxiety Disorder, Dementia, Chronic Obstructive Pulmonary Disease, Osteoarthritis, Gout, Heart Failure, and Age-related Nuclear Cataract - Bilateral. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/1/19 was reviewed. Resident #251 was coded as having a Brief Interview of Mental Status Score of 9, indicating moderately impaired cognition. Resident #251 was also coded as having impaired vision. In addition, she was coded as being independent in locomotion with a wheelchair. On 4/28/19 at approximately 4:00 P.M., an interview was conducted with Resident #251 at the nurse's station. Resident #251 stated, my wheelchair is shaky I may fall out, it's not safe. It rubs against the wheel. She noted that it was difficult to propel the wheelchair. She stated that…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to ensure residents' right to privacy during a Resident Group Interview. The facility Social Worker (Employee K) interrupted a private meeting and violated the residents right to privacy by walking into and throughout the meeting room uninvited. The Findings included: On 4/29/19 at 10:40 A.M., a private group interview was being conducted. There were two doors that led into the very large double room. Do not Disturb Resident Council Meeting in Progress signs were taped on the outside of both doors to ensure residents' privacy. Seven residents were in attendance and were actively participating. They majority of them voiced concerns about consistent shortages of staff, and stated that call bell response times sometimes took between 30 to 60 minutes. Suddenly, the social worker interrupted the resident group interview by entering the room without knocking on the door. She walked across the large room and looked around at all of the residents. In the meantime, another resident entered 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, clinical record review and facility documentation review, the facility staff failed to notify the physician and responsible party that medications were available for administration for one Resident (Resident # 128) in a survey sample of 60 residents. For Resident #128, the facility staff failed to notify the physician and responsible party of several medications that were unavailable for administration including, but not limited to: the breathing treatment medication Acetylcysteine Solution 20%, the thyroid medication- Levothyroxine 50 micrograms and the mood disorder medication, Depakote 250 milligrams. The findings included: Resident #128, a [AGE] year old male , was admitted to the facility on [DATE]. Diagnoses included but were not limited to: respiratory failure, hypertension, insomnia, dry eye syndrome, cerebral palsy, major depressive disorder, hypertension and diabetes. The most current Minimum Data Set assessment was a Significant Change 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 observation, and staff interview the facility failed to ensure a clean comfortable homelike environment for Residents in the Memory Care Unit, and Resident's # 146, and #14 in a survey sample of 60 Residents. 1. For the memory care Unit the facility staff was checking blood pressures and administering medications during breakfast meal. 2. Resident #146's room smelled strongly of urine and the floors were coated with a sticky dirty film. 3. Resident #14's room smelled strongly of urine and the floors were coated with a sticky dirty film The findings include: 1. For the memory care Unit the facility staff was checking blood pressures and administering medications during breakfast meal. On 4/29/19 at 8:00 AM the following observations were made at breakfast. At 8:35 AM while breakfast was going on observed LPN E was obtaining vital signs from a Resident who had a tray in front of them. At 8:35 AM LPN G was administering medications to a Resident with a tray in front of them. On 4/29/19 at 8:45 AM 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 Resident Representative interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure that appropriate information was communicated to the hospital for one Resident (Resident #105) in a survey sample of 60 Residents. For Resident #105, the facility staff failed to provide the receiving facility with a list of the resident's current medications at the time of transfer to the hospital. The findings included: Resident #105 was initially admitted to the facility on [DATE], with a readmission date of 4/24/19. Resident #105's diagnoses included but were not limited to: heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and chronic pain syndrome. Resident #105's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/22/19 was coded as an admission assessment. Resident #105 was coded as having a BIMS (brief interview for mental status) score of 8, which indicated…

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 documentation review and clinical record review, the facility staff failed to provide the bed hold policy to the resident and resident representative for one Resident (Resident #105) in a survey sample of 60 Residents. For Resident #105, the facility staff failed to provide the resident and resident representative with the bed hold policy at the time of transfer to the hospital. The findings included: Resident #105 was initially admitted to the facility on [DATE], with a readmission date of 4/24/19. Resident #105's diagnoses included but were not limited to: heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and chronic pain syndrome. Resident #105's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/22/19 was coded as an admission assessment. Resident #105 was coded as having a BIMS (brief interview for mental status) score of 8, which indicated moderate cognitive impairment. Resident #105…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation and clinical record review the facility failed to ensure Residents had (Pre admission Screening and Resident Review) PASARR Level II screening prior for 1 Resident (#97) in a survey sample of 60 Residents. 1. For Resident #97 the facility staff failed to obtain the required Level II screening done based on results of Level I. The Findings Include: Resident #97 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's disease, Type II Diabetes, Major Depressive Disorder, Restless Leg Syndrome, Sleep Apnea, and Reflux, Osteoarthritis. According to the admission Record the Resident was diagnosed with Dementia on 12/16/18 and Psychosis on 1/9/18 (a year after admission). According Resident's # 97's most recent (Minimum Data Set) MDS screening coded as a quarterly the Resident has a (Brief Interview of Mental Status) BIMS score of 12 indicating moderately impaired cognition. On 4/29/19 during clinical record review it was discovered that…

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 documentation and clinical record review the facility failed to ensure Residents had (Pre admission Screening and Resident Review) PASARR for 1 Resident (#169) in a survey sample of 60 Residents. For Resident #169 the facility staff failed to ensure a PASARR was obtained prior to admission. The findings include: Resident #169, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, Diabetes type 2, Delusional Disorder, Glaucoma, Hypertension, and Neuropathy. The Resident's most recent (Minimum Data Set) MDS screening was coded as a Quarterly Review with an (Assessment Reference Date) ARD of 4/3/19 coded the Resident as having a (Brief Interview of Mental Status) BIMS Score of 3 indicating severe cognitive impairment. On 4/30/19 during clinical record review it was noted that Resident #169 had a PASARR with the date of 4/12/19 and the Resident was admitted to the facility on [DATE]. On 4/30/19 at 5:10 in an interview with the DON…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed for two residents (Resident #113 and Resident #179) of 60 sampled residents to meet professional standards of quality. 1. For Resident #113, the facility staff failed to administer the correct physician ordered dose of oxygen. 2. For Resident #179, the facility staff failed to identify, assess, or treat a potential bowel elimination problem according to professional standards. The Findings included: 1. For Resident #113, the facility staff failed to administer the correct physician ordered dose of oxygen. Resident #113 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #113's diagnoses included Congestive Heart Failure, Hypertension, Chronic Kidney Disease, Anxiety Disorder, Dyspnea (shortness of breath), and Cardiomyopathy (enlarged heart). The Minimum Data Set, which was an Annual Assessment with an Assessment Reference Date of 3/17/19 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 observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide quality of care to 3 Residents (Resident #94, Resident #113, and Resident #179) in a survey sample of 60 Residents. 1. For Resident #94, the facility staff failed to apply adaptive devices as ordered by the physician. 2. For Resident #113, the facility staff failed to ensure that physician ordered continuous oxygen was available prior to transport from her room to the dining room. 3. For Resident #179, the facility staff failed to identify, assess, or treat a potential bowel elimination problem. The Findings included: 1. For Resident #94, the facility staff failed to apply adaptive devices as ordered by the physician. Resident #94, an [AGE] year old female who was admitted to the facility on [DATE] with diagnoses to include but not limited to high blood pressure, diabetes, right-sided paralysis following a stroke, and dementia. Resident #94's most recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, facility document review, and staff interview, the facility staff failed to provide services to prevent a decline in ROM (range of motion), and to increase range or motion, or prevent further decrease in ROM for one resident (Resident #14) in a survey sample of 60 Residents. For Resident #14, who was not admitted with contractures, the facility staff failed to provide ongoing assessment, services, equipment, and assistance, to maintain Range of Motion, or to prevent a further decline in ROM. The findings included: Resident #14, was originally admitted to the facility on [DATE]. The Resident was discharged and for this stay was readmitted for a medicaid stay on 7-1-15, according to the most recent (4-19-19) MDS (minimum data set) assessment prepared by the facility. Resident #14 was diagnosed on [DATE] with contracture, unspecified hand during stay in the facility. Other diagnoses for Resident #14 included but were not limited to: Arthritis, dementia, psychosis,…

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 documentation review, the facility staff failed to prevent a Significant Weight Loss for 2 (Resident #192 and #65) of 60 residents and maintain fluids for 1 (Resident #11) of 60 residents. 1. The facility staff failed to prevent a Significant Weight Loss of 10.59% within 34 days. In addition, the facility staff failed to recognize, evaluate and address Resident #192's nutritional needs in a timely manner. 2. For Resident # 65 the facility failed to prevent wt. loss of 10.5% in two months. 3. For Resident #11 the facility staff failed to provide fluids in the amounts ordered by physician. The Findings included: 1. The facility staff failed to prevent a Significant Weight Loss of 10.59% within 34 days. In addition, the facility staff failed to recognize, evaluate and address Resident #192's nutritional needs in a timely manner. Resident #192 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #192's diagnoses included…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, Resident interview and clinical record and facility documentation the facility staff failed to ensure Resident are provided adequate behavioral health services for 1 Residents (#180) in a survey sample of 60 Residents. For Resident # 180 the facility failed to provide adequate behavioral health services to prevent or manage behaviors exhibited by Resident #180. The findings included: Resident # 180 is an [AGE] year old man who was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's disease, Hypertension, and Dementia without behavioral disturbance, Anxiety Disorder, Major Depressive Disorder, and unspecified Psychosis not due to a substance or known physiological condition. On 4/29/19 during a clinical record review the following was discovered in the Progress Notes: 11/5/18 at 2:40 AM -Behavior Note At about 0215 Resident from room [redacted] approached this writer and said Resident from room [redacted] was in her room trying to get into bed with her and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, facility documentation and clinical record review the facility staff failed address psychosocial concerns for 1 Resident (#194) in a survey sample of 60 Residents. For Resident #194 the facility staff failed to provide adequate behavioral health services after a traumatic experience, leaving Resident #194 feeling unsafe at night. The findings include: Resident #194 a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Dementia without behavioral disturbance, Anxiety disorder, (Chronic Kidney Disease) CKD stage III, Major Depressive Disorder, Type II Diabetes, and Glaucoma. The Resident's most recent (Minimum Data Set) MDS coded as a quarterly assessment, coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 11 indicating moderate cognitive impairment. On 4/30/19 during clinical record review for another Resident the following was found in the nurse's note: 11/5/18 at 2:40 AM -Behavior Note At…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure medications were available for administration for one Resident (Resident # 128) in a survey sample of 60 residents. For Resident #128, several medications were unavailable for administration including, but not limited to: the breathing treatment medication Acetylcysteine Solution 20%, the thyroid medication- Levothyroxine 50 micrograms and the mood disorder medication, Depakote 250 milligrams. The findings included: Resident #128, a [AGE] year old male , was admitted to the facility on [DATE]. Diagnoses included but were not limited to: respiratory failure, hypertension, insomnia, dry eye syndrome, cerebral palsy, major depressive disorder, hypertension and diabetes. The most current Minimum Data Set assessment was a Significant Change assessment with an assessment reference date of 3/27/19. Resident #128 was coded with a Brief Interview of Mental Status score of 15 indicating no…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review the facility staff failed to provide a nourishing, well-balanced diet for three Residents (Resident #108, Resident #140, Resident #105) in a survey sample of 60 Residents. 1. For Resident #108, the facility staff ran out of food and failed to provide a well-balanced meal. 2. For Resident #140, the facility staff ran out of food and failed to provide a well-balanced meal. 3. For Resident #105, the facility staff ran out of food and failed to provide a well-balanced meal. The findings included: 1. For Resident #108, the facility staff ran out of food and failed to provide a well-balanced meal. Resident #108's diagnoses included but were not limited to: hypertension, Gastro-esophageal reflux disease, arthritis, anxiety and depression. Resident #108 was admitted to the facility on [DATE]. Resident #108's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/20/19, was coded as an annual assessment.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide food that accommodated resident needs for one resident (Resident #451) in a sample size of 60 residents. The facility staff served eggs to Resident #451 and she had an egg allergy. The findings included: Resident #451, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to fracture left distal humerus, osteoporosis, hypertension, vitamin D deficiency, hyperlipidemia, and gastroesophageal reflux disease. Resident #451 was admitted to the facility on [DATE] and therefore a Minimum Data Set assessment was not yet initiated. On 04/29/2019 at 9:15 AM, Resident #451 was observed sitting up in her wheelchair, dressed, and eating breakfast. When asked if she had any concerns, Resident #451 stated that she had to send the tray back this morning because the facility served her eggs for breakfast and she has an allergy to eggs. Resident #451 stated, If…

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 documentation review and clinical record, the facility staff failed to ensure 5 residents (Residents # 106, 115, 175, 30, and 95) were assessed (Level I) (1) or referred for Level II (2) PASARR (Preadmission Screening and Resident Review) after development of mental disorders. 1. For Resident # 106, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders. 2. Resident #115's PASARR was not dated. 3. Resident #175 did not receive a PASARR (preadmission screening and resident review) on admission. 4. Resident #30 did not have a Level I PASARR on admission. 5. For Resident #95, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders. The findings included: 1. For Resident # 106, the facility staff failed to ensure that a PASARR II was obtained after the development of mental disorders. Resident # 106 was admitted to the facility originally in 2005 and readmitted on [DATE] 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 staff interview, facility documentation review, and clinical record review, the facility staff failed for 8 residents (Resident #176, #55, #149, #193, #115, #8, #175, #93) of the survey sample of 37 to ensure a PASARR screening was conducted prior to admission to the nursing facility. 1. For Resident #176, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 2. For Resident #55, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 3. For Resident #149, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 4. For Resident #193, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. 5. Resident #115 was not referred for a Level II PASARR when diagnosed with bipolar disorder. 6. Resident #8 was not referred to for a Level II PASARR when diagnosed with paranoia. 7. Resident #175 was not…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed for 2 residents (#151, #95) in the sample size of 37 residents to provide facility sponsored individualized activities. 1. For Resident #151, the facility staff failed to provide individual activities. 2. For Resident #95, the facility staff failed to provide individual activities. The Findings included: 1. Resident #151 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #151's diagnoses included Psychosis, Anxiety Disorder, and Dementia. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 2/14/18, coded Resident #151 as having a Brief Interview of Mental Status Score of 3. This score is indicative of severely impaired cognition. On 3/14/17 a review was conducted of Resident #151's clinical record. The care plan read, 3/22/17. The resident sometimes interrupts group activities by yelling out, asking for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation review the facility staff failed for 1 resident (Resident #189) of 37 residents in the survey sample to ensure appropriate services were provided to prevent urinary tract infections. 1. Resident #189's catheter drainage bag and tubing were observed on the floor while resident was sleeping in bed. The findings included: Resident #189, an [AGE] year old, was admitted to the facility on [DATE]. Her diagnoses included urine retention, anxiety, dementia, depression, diabetes, dysphagia, and hyperlipidemia. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 3/2/18. Resident #189 had a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment. She required extensive assistance with activities of daily living. She was coded to have an indwelling catheter. Resident #189 had a physician order dated 3/14/18 for the catheter Foley catheter #16F with 10…

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 documentation review, clinical record review, the facility staff failed to to administer oxygen in a manner to prevent the spread of infection for one Resident (Resident # 15). For Resident # 15, on 03/13/18 the oxygen tubing was not dated as to when it had been changed. The findings included: 1. Resident # 15 was an [AGE] year old female admitted to the facility on [DATE] with the diagnoses of, but not limited to: Chronic Embolism, Major Depressive Disorder, Breast Cancer, COPD (Chronic Obstructive Pulmonary Disorder), Atherosclerotic Heart Disease, Chronic A-Fib (atrial fibrillation), IBS (Irritable Bowel Syndrome), Anxiety Disorder, Insomnia. The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 12/11/2017. The MDS coded Resident #15 with a BIMS (Brief Interview for Mental Status) of 14/15 indicating resident is cognitively intact. Resident # 15 requires extensive physical assist of one staff person 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 staff interview and clinical record review, the facility staff failed for 1 resident (Resident #103 ) of 37 residents in the survey sample to ensure medications were available for administration. For Resident #103, the breathing treatment medication Acetylcysteine Solution 20% was unavailable for administration. The findings included: Resident #103, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included respiratory failure, hypertension, insomnia, dry eye syndrome, cerebral palsy, and diabetes. The most current Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 1/23/18. Resident #103 was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. He required extensive assistance with activities of daily living. The following nursing notes were documented in the clinical record: 1/20/18 at 2:46 p.m. Pharmacy called and will send ASAP (as soon as possible). RP (responsible party) and MD (doctor) aware. 1/21/18…

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 documentation review, the facility staff failed for 1 resident (Resident # 151) in the survey sample of 37 residents, to review and renew a PRN (as needed) order for psychotropic medication every 14 days. The facility staff failed to review and renew a PRN order for Ativan for approximately 7 months. During that time, the order was never limited to 14 days duration. The Findings included: Resident #151 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #151's diagnoses included Psychosis, Anxiety Disorder, and Dementia. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 2/14/18, coded Resident #151 as having a Brief Interview of Mental Status Score of 3. This score is indicative of severely impaired cognition. On 3/14/17 a review was conducted of Resident #151's clinical record. The care plan read, 3/22/17. The resident sometimes interrupts group activities by yelling out,…

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.