Clarksville Health & Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice for 3 Residents (Resident #1, #2, and #3) in a survey sample of 8 Residents. For Resident #1, #2, and #3, the facility staff failed to administer medications in accordance with physician orders and failed to notify the physician that the ordered medications were not administered. The findings included: On 11/27/23 and 11/28/23, clinical record reviews were performed. This review revealed the following: 1. For Resident #1, the facility staff documented on 11/27/2023 at 6:21 PM, Medication Administration Note: Ativan Oral Tablet 0.5 MG, give 1 tablet by mouth every 6 hours related to anxiety disorder unspecified, not available from pharmacy. Review of the Medication Administration Record (MAR) revealed that the Ativan was not administered on 11/27/23. There was no indication that the physician was made aware of the missed dose. 2. Resident #2 had the following…

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

Based on observation, staff interview, and clinical record review, the facility staff failed to provide adequate devices and interventions to maintain a safe environment to prevent accidents, affecting two Residents (Resident #1 and #4) in a survey sample of 8 Residents. The findings included: 1. For Resident #4, the facility staff failed to ensure Dycem (a non-slip device) was in place, which was used as a fall intervention to reduce the risk of a repeat fall. On 11/27/23 at 2:05 PM, Resident #4 was observed being assisted to the bathroom by CNA B. CNA B was asked that once Resident #4 was in a standing position that the Surveyor be permitted to look at her wheelchair. There was a cushion in the wheelchair, CNA B lifted the cushion and confirmed that dycem was not in the wheelchair. On 11/27/23, a clinical record review revealed that Resident #4 had a care plan focus area that identified the resident as being at risk for falls. Interventions included, but were not limited to, Dycem in wheelchair by md orders. 2. For Resident #1, the facility staff failed to ensure that fall…

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

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure a GDR (gradual dose reduction) for one 22 residents in the survey sample, Resident #59. Findings include: Resident #59's diagnoses included but were not limited to: high blood pressure, atrial fibrillation, Vitamin D deficiency, hypothyroidism, major depressive disorder, and anxiety disorder. The resident's most recent MDS (minimum data set) was a quarterly review dated 08/28/22. The resident was assessed with a cognitive score of 15, indicating the resident was intact for daily decision making skills. The resident was assessed as requiring extensive to full assistance most all ADL's (activities of daily living). On 11/30/22 at 8:00 AM, Resident #59's clinical records were reviewed. A pharmacy recommendation dated 03/21/22 documented, .(Name of Resident #59) received buspirone (Buspar) 10 mg (milligrams) TID (three times daily) for GAD (generalized anxiety disorder) .Please attempt a gradual dose reduction [GDR] with the end goal of discontinuation . The resident'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.

Based on resident interview, staff interview and clinical record review, the facility failed to develop a care plan for one of 22 resident's in the survey sample. The Findings Include: Resident #66 did not have a care plan for bowel and bladder incontinence. Diagnoses for Resident #66 included; Dysphagia, chronic obstructive pulmonary disease, bowel and bladder incontinence. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 10/12/2022. Resident #66 was assessed with a cognitive score of 12 indicating cognitively intact. Section G (Activities of Daily Living) of the current MDS documented Resident #66 needs extensive assistance with one person physical assist for toilet use. Section F (Bladder and Bowel) of the MDS documented Resident #66 is frequently incontinent of bladder and bowel. On 11/30/22 at 8:13 AM Resident #66 was interviewed regarding incontinence and verbalized that she sometimes knows when she has to use the bathroom but a lot of times she has soiled herself and the aides will clean her up. Resident #66 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure an initial assessment was completed at the time of admission for one of 22 residents, Resident #98. Findings were: Resident #98 was system selected and added to the survey sample as a closed record due to her death in facility. She was admitted to the facility with end stage renal disease, type II diabetes mellitus, atrial fibrillation, and hypertension. No MDS (minimum data set) was completed. The clinical record was reviewed on [DATE] at approximately 3:00 p.m. Documentation in the clinical record was limited. There were two progress notes observed and contained the following: [DATE] 07:27 (a.m.) 0525 (5:25 a.m.) Resident found with no respirations and cold to touch, 0535 (a.m.) RN (registered nurse) in facility pronounced death, 0545 (a.m.) .Hospice notified of death. DON (director of nursing) notified of death. 0555 (a.m.) RP (responsible party) notified of death and requested services of (Name…

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 document review, the facility staff failed to label opened insulin pens on one of four nursing units. Two insulin pens stored in a medication cart on [NAME] unit were not marked with the date opened to ensure proper storage. The findings include: On 11/28/22 at 1:25 p.m., accompanied by registered nurse unit manager (RN #1), a medication cart was inspected on [NAME] unit. Stored in the cart were two insulin pens. The pens (Novolog flexpen 100 units/milliliter; Lantus Solostar insulin pen 100 units/milliliter) labeled for a current resident were opened and had no date opened or discard date written on the pen. On 11/28/22 at 1:26 p.m., RN #1 was interviewed about the insulin pens with no date opened. RN #1 stated insulin pens were supposed to be labeled when opened for storage on the cart and discarded according to retention recommendations. RN #1 stated she was unable to know how long the pens had been opened since the date was not marked on the pen. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for one of 20 residents in the survey sample. Nurses documented duplicate administration of the controlled medication lorazepam to Resident #38 for 27 consecutive days and failed to correct duplicate physician orders and entries on the resident's medication administration record (MAR). The findings include: Resident #38 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (stroke), urinary tract infection, anemia, hypertension, anxiety and depression. The minimum data set (MDS) dated [DATE] assessed Resident #38 with moderately impaired cognitive skills. Resident #38's clinical record documented a physician's order dated 3/3/21 for the controlled medication lorazepam 0.5 milligrams (mg) two tablets to be administered at bedtime for treatment of anxiety. The physician orders included a duplicate order for lorazepam 0.5 mg two…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to follow physician orders for two of 20 residents in the survey sample. Resident #38 was administered an incorrect dose of the controlled medication Ativan (lorazepam). Fluid intake for Resident #22 was not monitored as ordered by the physician. The findings include: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (stroke), urinary tract infection, anemia, hypertension, anxiety and depression. The minimum data set (MDS) dated [DATE] assessed Resident #38 with moderately impaired cognitive skills. Resident #38's clinical record documented a physician's order dated 3/3/21 for lorazepam (Ativan) 0.5 milligrams (mg) two tablets to be administered at each bedtime for treatment of anxiety. Review of Resident #38's medication administration record and the controlled medication count sheet for lorazepam documented a discrepancy in the dosage given on 3/28/21. Resident #38'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.

Based on employee record review, staff interview andfacility document review, the facility staff failed to implement policies andprocedures for abuse prevention for 3 of 25 staff. One personnel file did not contain a sworn statement and two personnel files did not contain a sworn statementor criminal background check. Findings include: A review of 25 personnel files was conducted on 04/01/21 at approximately 8:00 AM. A file of one employee (a Licensed Practical Nurse [LPN]), did not include a sworn statement and the files of three employees (two LPNs and an RN [Registered Nurse]) did not include sworn statements or a criminal background check conducted by the Virginia State Police. On 04/01/21 at approximately 8:40 AM, the administrator stated that she did not think that these employees needed these documents, as they were considered vendors. The administrator was asked for a policy on screening new employees. A policy titled, Employee background screening documented, .background and licensure checks on all new employees and volunteers .all applicants and new employees must certify…

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 review and revise the comprehensive care plan for two of 20 residents in the survey sample. Resident #38's care plan was not updated regarding interventions for contractures. Resident #427's plan of care was not updated to include care of oxygen administration equipment. The findings include: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (stroke), urinary tract infection, anemia, hypertension, anxiety and depression. The minimum data set (MDS) dated [DATE] assessed Resident #38 with moderately impaired cognitive skills and impaired range of motion of the left upper and lower extremities. On 3/30/21 at 11:23 a.m., Resident #38 was observed in bed. The resident's left wrist and fingers on the resident's left hand were contracted. The resident held her left arm/hand close to her chest with the fingers on her left hand touching her palm.…

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 implement interventions to address hand/wrist contractures for one of 20 residents in the survey sample. Resident #38, with contractures in her left hand/wrist had no interventions in place to prevent a further decrease in range of motion. The findings include: Resident #38 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (stroke), urinary tract infection, anemia, hypertension, anxiety and depression. The minimum data set (MDS) dated [DATE] assessed Resident #38 with moderately impaired cognitive skills and impaired range of motion of the left upper and lower extremities. On 3/30/21 at 11:23 a.m., Resident #38 was observed in bed. The resident's left wrist and fingers on the resident's left hand were contracted. The resident held her left arm/hand close to her chest with the fingers on her left hand touching her palm. There were no positioning and/or…

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

Based on a medication pass and pour observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a medication error rate of less than 5%. The facility had 31 medication opportunities with two medication errors, which resulted in a medication error rate of 6.45%. Findings include: On 03/31/21 at approximately 7:50 AM, LPN (Licensed Practical Nurse) #3 prepared medications for Resident #47. LPN #3 removed Resident #47's medication cards from the cart and prepared to dispense the medication pills into a cup. LPN #3 dispensed six medications and one, half tablet into the cup. The half tablet was identified from the medication card, which documented: .CITALOPRAM .20MG TABLET Give 1.5 tablet [30 mg] by mouth one time a day for depression. This card only had half tablets, which were 10 mg each. LPN #3 administered the medications to the resident. Resident #47 only received one half tablet, which was 10 mg and not 30 mg of citalopram as ordered by the physician. Resident # 47's physician's orders documented, .Citalopram .20 mg…

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 document review, the facility staff failed to ensure drugs and biologicals were stored in accordance with professional standards of practices in one of three medication storage rooms, and on one of five medications carts. Findings include: On 03/31/21 at 9:39 AM, the medication room on the 100/200 unit was observed with RN (Registered Nurse) #1 (nursing supervisor). The narcotic lock box inside the refrigerator was unlocked by RN #1 for observation. The RN removed two small plastic bags, each bag contained two, unopened 1 ml (milliliter) vials of Lorazepam [2mg/ml]. One of the bags belonged to Resident #7 (a current resident of the facility). The medication bag was labeled with the resident's name and dated 2020. The other bag containing the other two vials of Lorazepam had a resident name, which was not found in the facility's electronic record [identified as Resident #00]. This medication had the resident's name and dated 2019. RN #1 stated that she did 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 staff interview and clinical record review, the facility staff failed to ensure physician ordered laboratory services were obtained for one of 20 residents, Resident #278. The Finding Include: Resident #278 was admitted to the facility on [DATE]. Diagnoses for Resident #278 included: Chronic obstructive pulmonary disease, cirrhosis of liver, protein calorie malnutrition, alcohol dependence with withdrawal. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 3/29/21. Resident #278 was assessed with a cognitive score of 14 indicating cognitively intact. On 3/30/21 Resident #278's medical record was reviewed. A physician's order dated 3/25/21 documented CBC [complete blood count], CMP [chemical metabolic panel], Mag [magnesium], phos [phosphorus], pre-Albumin in a.m. Lab results for Resident #278 were not found in the clinical record. On 03/31/21 at 8:10 AM, medical records staff (Other staff OS #1) was interviewed. OS #1 said when labs test are…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility failed to ensure a complete and accesible medical record for one of 20 residents in the survey sample, Resident #47. The care plan for Resident #47 was not in the electronic medical record, and was not available/accesible to direct care staff on the unit where the resident resided. The Findings Include: Resident #47 was admitted to the facility on [DATE]. Diagnoses for Resident #47 included; Guillain-Barre syndrome, chronic kidney disease, and neurogenic bladder. The most current MDS (minimum data set) was a annual assessment with an ARD (assessment reference date) of 2/5/21. Resident #47 was assessed with a cognitive score of 15 indicating cognitively intact. On 03/30/21 at 02:08 Resident #47 was interviewed. Resident #47's Foley catheter was observed during the interview and Resident #47 was asked how often the catheter was changed. Resident #47 was unsure how often the catheter was changed. On 03/30/21 Resident #47's current…

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

Based on observation, staff interview, resident interview, group interview, and facility document review, the facility staff failed to ensure appealing, alternate food options of similar nutritive value were available for residents. The facility staff failed to provide appealing, alternate food options of similar nutritive value to residents who do not eat food that was initially served or had requested a different meal choice, and failed to ensure that the alternate food options were clearly communicated and/or documented for resident knowledge of optimum alternate food choices. Findings include: An initial tour and observation of the kitchen was conducted on 01/29/19 at 11:15 AM. During the initial observation food temperatures were completed on the lunch menu items. The DM (dietary manger) was asked what the alternate food items for today were available for residents. The DM stated that they (the facility) did not have alternate food items. The DM was asked if a resident doesn't like what is being served, what alternate food choices do they have. The DM stated that the residents…

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

Based on observation, staff interview and facility policy review, the facility staff failed to develop and implement a water management program to identify the risk of Legionella, and also failed to perform hand hygiene during meal service. 1. The facility staff failed to develop and implement a water management program to identify the risk of Legionella. 2. A nurse failed to perform hand hygiene between residents during a meal observation on the Honeysuckle unit. Findings include: 1. On 1/29/19 at 1:30 p.m. the facility administrator was asked for the Legionella identification program. The administrator stated she would get with staff responsible and bring to the conference room. On 1/30/19 at 2:30 p.m. the non-clinical services director, other staff (OS) # 2, came to the conference room to ask what was needed. OS # 2 was told the Legionella water management protocol was needed for review. OS # 2 stated I think that's in the Emergency Preparedness book. OS # 2 then left the room and returned a few minutes later stating You're correct; what's in the Emergency book isn't 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 resident interview, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to develop a CCP (comprehensive care plan) for the care and services for three of 28 residents in the survey sample, Resident #115, #106 and #101. 1. The facility staff failed to develop a CCP for Resident #115's AV (arteriovenous) graft (hemodialysis) access site for the provision of care and assessment with interventions. 2. Resident #106 did not have a care plan to address antipsychotic medications. 3. Resident #101 had no care plan developed regarding a leaking ileostomy and a skin rash/excoriation from contact with the leaking liquid stool. Findings include: 1. Resident #115 was admitted to the facility originally on 06/14/18. Diagnoses for Resident #115 included, but were not limited to: history of chronic alcohol use, DM (diabetes mellitus) requiring insulin, HTN (high blood pressure), seizure disorder, acquired absence of right below the knee amputation, and end…

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 complaint investigation, the facility staff failed to assess and implement interventions for care of an ileostomy for one of 28 residents in the survey sample. Resident #101 was observed with a leaking ileostomy bag and red, excoriated skin in the area of the leaking stool. The facility failed to assess and implement interventions for the excoriated skin related to the leaking ileostomy. The facility staff failed to initiate and/or implement interventions to prevent stool leakage from the ileostomy that direct care staff stated had been ongoing for at least three months. The findings include: Resident #101 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #101 included chronic atrial fibrillation, atherosclerotic heart disease, diabetes, high blood pressure, anemia, ileostomy due to diverticulosis, history of gastrointestinal bleed, neurogenic bladder and dementia. The minimum data set (MDS) dated [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 and clinical record review, the facility staff failed to ensure care and services of a hemodialysis catheter access site was provided for one of 28 residents in the survey sample, Resident #115. The facility staff failed to assess Resident #115's AV graft (hemodialysis) access site for the provision of care, assessment and care planning. The facility staff were not assessing the resident's AV (arteriovenous) graft on a daily basis to ensure proper blood flow and/or assess for any changes or potential complications related to a hemodialysis access site. Findings include: Resident #115 was admitted to the facility originally on 06/14/18. Diagnoses for Resident #115 included, but were not limited to: history of chronic alcohol use, DM (diabetes mellitus) requiring insulin, HTN (high blood pressure), seizure disorder, acquired absence of right below the knee amputation, and end stage renal failure (dependent on renal/hemodialysis). The most recent MDS (minimum data base),…

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

Based on resident interview, group interview, facility document review and staff interview, the facility staff failed to respond to call bells in a timely manner. During interviews, multiple residents stated they waited at times from 30 minutes to one hour for staff response to call bells. The findings include: On 1/29/19 at 11:40 a.m., Resident #81 was interviewed about quality of care/life in the facility. When asked about staff response to call bells, Resident #81 stated he frequently waited 30 minutes for call bell response, especially when he was in the bathroom. Resident #81 stated he was able to get into the bathroom independently but required assistance for getting clothing back on after using the bathroom. Resident #81 stated he frequently waited 30 minutes or more for assistance from the bathroom, depending on which aides were working. Resident #81 stated he had talked with nursing about the slow response but had not seen the times improve. On 1/30/19 at 10:00 a.m., an interview was conducted with a group of seven cognitively intact residents regarding quality of care/life…

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 a dignified dining experience on one of five living units. Without seeking the resident's permission, a nurse administered an injection to a resident in front of others during the lunch meal on the Honeysuckle unit. In addition, a nurse stood beside two residents while feeding them their lunch. The findings include: A meal observation was conducted on the Honeysuckle unit on 1/29/19 from 11:45 a.m. until 12:30 p.m. On 1/29/19 at 11:53 a.m., licensed practical nurse (LPN) #6 was observed giving a male resident an injection in his right upper arm. The resident was seated at a table near the kitchenette with two other residents at the same table and multiple other residents and staff in the dining area. LPN #6 pulled back the resident's shirtsleeve then administered the injection with no prior permission from the resident. On 1/29/19 at 12:11 p.m., LPN #6 was observed feeding several bites of food to a resident while standing beside her. LPN #6 then went to the right side of another resident at the same table…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, the facility staff failed to follow physician's orders for treatment and care of skin integrity for one of 28, Resident #91. Resident #91 did not have physician ordered heel protectors on while in bed. The Findings Include: Resident #91 was admitted to the facility on [DATE]. Diagnoses included: Muscle contractures, osteoarthritis, lower extermety edema, and stage 3 pressure ulcer to sacral area. The most current MDS (minimum data set) was a significant change assessment with an assessment reference date (ARD) of 12/26/18. Resident #91 was assessed with a cognitive score of 15, indicating cognitively intact. On 01/29/19 at 2:36 PM, Resident #91 was interviewed. Resident #91 was laying in bed; a pair of Prevlon boots (used to protect heels) were observed in a chair beside the bed. Resident #91 was asked if there were any open wound areas. Resident #91 verbalized that he had an open area to his bottom. After completing an interview with Resident…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to anchor the tubing for a Foley urinary catheter for one of 28 residents in the survey sample. Resident #101 did not have the Foley catheter tubing anchored to her thigh as ordered by the physician and required in her plan of care. The findings include: Resident #101 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #101 included chronic atrial fibrillation, atherosclerotic heart disease, diabetes, high blood pressure, anemia, ileostomy due to diverticulosis, history of gastrointestinal bleed, neurogenic bladder and dementia. The minimum data set (MDS) dated [DATE] assessed Resident #101 with severely impaired cognitive skills and as totally dependent on one person for hygiene, bathing and toileting. On 1/30/19 at 9:25 a.m., accompanied by licensed practical nurse (LPN #5), Resident #101's Foley catheter tubing was observed. The urinary catheter tubing was not anchored in any…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review, facility staff failed to provide a diet per physician order for one of 28 residents in the survey sample, Resident #2. Facility staff failed to provide finger foods per physician order for Resident #2 at each meal. Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Dementia with psychosis, Alzheimer's Disease, Macular Degeneration, Insomnia, and Anxiety. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/11/19. Resident #2 was assessed as impaired in her short and long term memory and moderately impaired in her daily decision making skills. Resident #2 was observed on 01/29/19 at approximately 12:00 p.m. with lunch that consisted of lasagna, broccoli and green beans. She was observed on 01/30/19 at 8:35 a.m. with breakfast that consisted of cereal with bananas, egg omelet, ham, toast and pudding. Resident #2's 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 observation, and staff interview, the facility staff failed to ensure expired biological's were not readily available for use on one of 5 units. Expired lab collection tubes were readily available for use on the Primrose unit. The Findings Include: On [DATE] at 10:15 AM, storage of medications and biological's were observed on the Primrose unit. Three lab collection tubes were observed by this surveyor and license practical nurse (LPN #1) to be expired and mixed in with lab tubes that were not expired. Two of the lab tubes had an expiration date of [DATE] and one lab collection tube had an expiration date of [DATE]. LPN #1 was interviewed concerning the finding. LPN #1 verbalized that all nurses should be checking for expiration dates and discarding any lab tubes that are expired so the tubes couldn't be used. On [DATE] at 4:22 PM, the above information was brought to the attention of the director of nursing (DON) and administrator during an end of day staff meeting. The DON and administrator were…

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.