Alleghany Health And Rehab

Based on observation, staff interviews and facility documentation the facility staff failed to conduct annual performance reviews for one certified nursing assistant (CNA #14) in a sample of three certified nursing assistants reviewed. The findings included: The facility staff failed to complete an annual evaluation yearly on one certified nursing assistant, CNA#14 (CNA14). On 1/28/25 at 10:00 a.m. a review of employee records was conducted. During the review of the employee records CNA14 was hired on 6/12/22 and the first evaluation in her record was completed on 1/27/25, which was after the surveyor had requested the employee files. On 1/28/25 at 11:00 a.m. an interview was conducted with the director of nursing (DON). The surveyor informed the DON that the evaluation had not been completed yearly and that the one in the employee file was completed on 1/27/25 and most of the evaluations was given verbal consent by the employee. The DON stated that the purpose of the annual evaluations was to keep up with the employee's performance and to discuss the area's that may need…

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, clinical record review, and facility documentation review, the facility staff failed to utilize outside resources to ensure ongoing psychiatric services were available to residents needing such service, having the ability to affect residents on 3 of 3 nursing units. The findings included: The facility staff failed to provide outside resources to ensure ongoing and consistent psychiatric services were available to all residents who may have required mental health services, as they had no routine provider from October 2024 until 1/23/25. On 1/24/25 at 2:30 p.m., an interview was conducted with the medical nurse practitioner, who is the primary provider at the facility. During this interview, the nurse practitioner said, We have not had an on-site psychiatric provider since I have been here and have only had 1 telehealth psych visit. From what I am told, we now have a psych provider who will be coming. According to the facility assessment provided to the survey team, the facility noted, Resident/Facility Data which noted, 66 residents with…

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

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement policies and procedures for ensuring the reporting of reasonable suspicion of abuse violations, resulting in the failure to protect residents from further potential abuse by an alleged perpetrator, as required for three residents (Resident #8, Resident #16, and Resident #17), in a survey sample of 19 residents. The findings included: 1. For Resident #8 (R8) who was a target and victim of abuse by Resident #16 on multiple occurrences, the facility staff failed to protect R8 from further potential abuse and failed to report each of the alleged violations of abuse, as required. On 1/22/24 at approximately 9:30 a.m., during an interview with resident #8 (R8), the resident verbalized to the surveyor and facility Administrator that Resident #16 (R16) had told R8 to Suck my di*k. R8 went on to state that she had been molested three times in the past and I just can't handle this. The current administrator was observed taking notes during this…

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, clinical record review, and facility documentation review, the facility staff failed to conduct a thorough investigation into allegation of abuse and neglect involving two residents (Resident #8 and Resident #17) in a survey sample of 19 residents. The findings included: 1. For Resident #8 (R8), who reported an allegation of being abused by Resident #16 (R16), the facility administration failed to conduct a thorough investigation. On 1/22/24 at approximately 9:30 a.m., during an interview with resident #8 (R8), the resident verbalized to the surveyor and facility Administrator that Resident #16 (R16) had told R8 to Suck my di*k. R8 went on to state that she had been molested three times in the past and just can't handle this. The current administrator was observed taking notes during this interview. On 1/22/25 -1/23/25, a clinical record review was conducted of R8 clinical record. R8's diagnosis included, but were not limited to major depressive disorder, insomnia, generalized anxiety disorder, borderline personality disorder, bipolar…

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

Based on observation, resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for two residents (Resident #8-R8 and Resident #16-R16), in a survey sample of 19 residents. The findings included: On 1/22/25 at approximately 9:30 a.m., R8 was interviewed in her room. During the conversation, R8 began making reports of being threatened by the prior administrator. The surveyor requested that the resident allow the surveyor to get someone from facility administration to be a part of the conversation to hear what she was reporting. The facility's interim administrator then accompanied the surveyor back to R8's room. R8 continued to report allegations with regards to the prior facility administrator and then identified resident #16 (R16) by name and reported, [R16's name redacted] says he is going to kill me or says suck my dk. I don't like it because I wasn't raised like that. I have been molested three times and I just can't handle this! On 1/22/25 -1/23/25, a clinical record review…

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 provide behavioral health services to two residents (resident #8- R8 and resident #16-R16) in a survey sample of 19 residents. The findings included: 1. For R8, who had psychiatric conditions and was a trauma survivor, the facility failed to provide consistent behavioral health services. On 1/22/25 at approximately 9:30 a.m., R8 was interviewed in her room. During the conversation, R8 began making reports of being threatened by the prior administrator. The surveyor requested that the resident allow the surveyor to get someone from facility administration to be a part of the conversation to hear what she was reporting. The facility's interim administrator then accompanied the surveyor back to R8's room. R8 identified resident #16 (R16) by name and reported, [R16's name redacted] says he is going to kill me or says suck my d*ck. I don't like it because I wasn't raised like that. I…

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

Based on observation, staff interviews, resident interviews, and facility documentation, the facility staff failed to provide meals at an appetizing temperature for residents on one of three units. The findings included: The staff failed to serve residents food that reached an appropriate temperature to be appetizing. On 1/21/25 at 11:45 a.m., a tour of the kitchen was conducted. During the tour the temperature logs were reviewed and the steam table where the food was being served. No issues were noted during the tour. On 1/21/25 at 12:15 p.m., the lunchtime meal was observed. The meal cart reached the A-wing at 12:20 p.m. The surveyor had requested a test tray be placed on the meal cart, and the test tray was obtained at 12:35 p.m., as the last resident tray was being served. The meal served was a cheeseburger, mashed potatoes, cole slaw, and a fruit bowl. The regional dietary manager was present, and temperatures were obtained. The hot foods were observed as not reaching the proper temperatures. The cheeseburger temperature was 90 degrees, and mashed potatoes were 120 degrees. The…

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

Based on staff interviews and facility documentation, the facility staff failed to provide Quality Assurance and Performance Improvement (QAPI) training for one employee (the director of nursing) in a survey sample of 10 employee records reviewed for training. The findings included: The facility staff failed to have the required QAPI training for one employee, the director of nursing. On 1/27/25 at approximately 2:00 p.m., the surveyor requested 10 employee's files as part of the sufficient staffing and extended survey training review. The list of employees was given to the staff development coordinator, a registered nurse, RN#5 (RN5). On 1/28/25 at 9:00 a.m., the employee files were obtained from R5 and reviewed. During the review of the staff files for training, the director of nursing had not completed Quality Assurance and Performance Improvement training for the year 2024. She completed her training on the morning of 1/28/25, after the training records has been requested by the surveyor. On 1/28/25 at 12:45 p.m., a meeting was held with the regional vice president of…

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

Based on staff interviews and facility documentation, the facility staff failed to provide annual infection control training for one employee (the director of nursing) in a survey sample of 10 employee records reviewed. The findings included: The facility staff failed to have the required annual infection control training for one employee. On 1/27/25 at approximately 2:00 p.m. the surveyor requested 10 employee's files for the sufficient staffing and extended survey training review. The list of employees was given to the staff development coordinator, a registered nurse, RN#5 (RN5). On 1/28/25 at 9:00 a.m. the employee files were obtained from R5 and were reviewed. During the review of the staff files for training, the director of nursing, who was the infection preventionist for the facility had not completed her annual infection control training for 2024. On 1/28/25 at 11:00 a.m. an interview was conducted with the director of nursing (DON). The director of nursing brought her infection control in long term care facilities certificate and stated that she was sure she had completed…

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 in the course of this investigation, it was determined that the facility staff failed to provide a home like environment on 3 of 3 units in the facility. The findings include: On 3/12/24 at 8:00 AM the following was observed on A-wing: Resident room A-5 bedroom wallpaper beside the window and in bathroom was peeling off the wall, ceiling tiles in bedroom had brown stains Resident room A-6 bathroom wallpaper was peeling off the wall Resident room A-7 ceiling tiles in the bedroom had brown stains, sink was loose and in need of repair Resident room A-8 wallpaper was stapled to the wall, plaster on the wall had not been sanded and painted Resident room A-10 bedroom wall behind the bed had plaster that had not been sanded and painted Resident room A-16 bedroom ceiling tiles had brown stains Resident room A-18 bedroom had holes in the wall beside the bathroom, black scuff marks on the wall behind the bed Resident room A-19 ceiling tiles in bathroom had brown stains, bedroom had gouges in the wall with no repair Resident room A-21 bedroom wall had…

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 document review the facility failed to implement resident to resident abuse policies for three of five residents (Resident #2, #3, and #4). The facility failed to implement resident to resident abuse policies in regard to sexual abuse for Resident #2 (R2) and failed to implement resident to resident verbal abuse and aggressive behavior policies for R3 and R4. The Findings Include: According to the clinical record, diagnoses for R1 included Dementia, bipolar, anxiety, and mood disturbance. The most current MDS (minimum data set - assessment tool) was a quarterly assessment with an According to the clinical record,ARD (assessment reference date ) of 11/30/24, which assessed R1 with a cognitive score of 14 out of 15, indicating cognitively intact for daily decision making. According to the clinical record, diagnoses for R2 included Dementia, anxiety, major depression, and cognitive communication deficit. The most current MDS (minimum…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to report suspicion of resident to resident sexual abuse for one of 5 residents and failed to report allegation of resident to resident verbal abuse for two of 5 residents. 1. The facility did not report resident to resident sexual encounters between Resident #1 (R1) and R2 on two occasions. 2. The facility failed to report resident to resident verbal and aggressive behavior between R1 and R3. 3. The facility failed to report resident to resident verbal and aggressive behavior between R1 and R4. The Findings Include: 1. Diagnoses for R1 included Dementia, bipolar, anxiety, and mood disturbance. The most current MDS (minimum data set - ) was a quarterly assessment with an ARD (assessment reference date) of 11/30/24, which assessed R1 with a cognitive score of 14 out of 15, indicating cognitively intact for dailyassessment tool decision making. Diagnoses for R2 included Dementia, anxiety, major…

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 document review, the facility failed to thoroughly investigate resident to resident abuse allegations for three of five residents, Resident # 2, #3, and #4. The facility failed to investigate resident to resident abuse in regard to sexual abuse for Resident #2 (R2) and failed to investigate resident to resident verbal abuse and aggressive behavior for Resident #3 (R3) and Resident #4 (R4), which were perpetrated by Resident #1 (R1). The Findings Include: Diagnoses for R1 included Dementia, bipolar, anxiety, and mood disturbance. The most current MDS (minimum data set - assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 11/30/24, which assessed R1 with a cognitive score of 14 out of 15, indicating cognitively intact for daily decision making. Diagnoses for R2 included Dementia, anxiety, major depression, and cognitive communication deficit. The most current MDS (minimum data set) was an annual…

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 staff and resident interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to provide effective administration regarding abuse prevention and the provision of behavioral health services, resulting in the identification of immediate jeopardy and substandard quality of care being identified, which had the potential to affect multiple residents. The findings included: The facility administration failed to administer the facility in an effective manner to address the behavioral health needs of 3 Residents for sexual and verbal abuse. On 3/12/24, during clinical record reviews, the following was noted: 1A. Review of a social worker note (for R2) dated 6/5/23 documented: SSD [social service director] contacts resident's guardian and leaves a message requesting a return call to discuss resident's relationship with another resident. Another social worker note (for R2) dated 6/5/23 documented: SSD speaks with resident's guardian who states that resident cannot be alone in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to develop a care plan for two of five residents in the survey sample (Residents #3 and #4). 1. The facility did not develop a psychosocial care plan for Resident #3 (R3). 2. The facility did not develop a psychosocial care plan for Resident #4 (R4). The findings include: 1. During the review of an event summary related to abuse, the survey team added R3 to the sample. According to the clinical record, R3 has diagnoses of anxiety and depression. R3's most current quarterly MDS (minimum data set - assessment tool) dated 1/11/24, assessed R3 as being moderately intact cognitively for daily decision making, with a score of 7 out of 15. The facility presented two Concern Form[s] regarding R3 dated 2/14/24 and 2/19/24. The concern form dated 2/14/24 indicated R3 was being harassed by R1 with romantic advances and was feeling unsafe and uncomfortable due to the advances and verbal statements. The documentation indicates that R1 was spoken…

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 review and revise the comprehensive care plan for two of five residents in the survey sample (Residents #1 and #2). 1. Resident #1 (R1) behavior care plan was not revised to include sexual behaviors. 2. Resident #2 (R2) behavior care plan was not revised to include sexual behaviors. The findings include: 1. According to the clinical record, diagnoses for R1 included Dementia, bipolar, anxiety, and mood disturbance. The most current MDS (minimum data set - assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 11/30/24, which assessed R1 with a cognitive score of 14 out of 15, indicating cognitively intact for daily decsion making. R1's social worker note dated 7/6/23 documented: SSD and [name of nurse] RN, have a conversation with resident re his relationship with another resident. The other resident's guardian has expressed that there can be no intimate relationship. This resident expresses…

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 staff failed to assess and implement behavioral health interventions regarding sexual and verbal abuse for one of five in the survey sample, Residents #1 (R1). The findings include: Facility staff failed to identify and implement non-pharmacological interventions to address Resident #1's sexual and aggressive behavioral health needs towards other residents. According to the clinical record, R1 was displaying sexual behaviors towards R2 (who is severely cognitively impaired with a BIMS score of 3 out of 15) on 6/11/23, 6/15/23, and 7/20/23. R1 also showed verbal abuse and aggressive behavior towards R3 on 2/14/24 and 2/19/24 and inappropriate behaviors toward R4 on 2/14/24. R1 was admitted to the facility with diagnoses that included dementia, bipolar, anxiety, and mood disturbance. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/30/24, which assessed R1 with a cognitive score of 14 out of 15, indicating cognitively intact for daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide medically-related social services in response to verbal abuse for two of five residents (Residents #3 and #4). 1. The facility did not provide care planning and outside services related to coping with verbal abuse for Resident #3 (R3). 2. The facility did not provide care planning and outside services related to coping with verbal abuse for Resident #4 (R4). The findings include: 1. During the review of an event summary related to abuse, the survey team added R3 to the sample. According to the clinical record, R3 had diagnoses of anxiety and depression. R3's current quarterly MDS (minimum data set - assessment tool) dated 1/11/24, assessed R3 as having moderately intact cognition for daily decision making, with a score of 7 out of 15. The facility presented two Concern Form[s] regarding R3 dated 2/14/24 and 2/19/24. The concern form dated 2/14/24 indicated R3 was being harassed by R1 with romantic…

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

Based on observation, staff interview, and facility document review, the facility staff failed to prepare and serve food in a sanitary manner from the main kitchen. The findings include: Food items were held and served from the steam table below 135 degrees F during lunch service on 4/25/23. The kitchen's fryer and stove top were dirty with accumulated grease/lint. Dishwashing was observed with the wash water temperature below the manufacturer's minimum temperature of 150 degrees F. On 4/25/23 at 11:37 a.m., food service from the main kitchen's steam table was observed. Temperatures of food held on the steam table included the following in degrees F: chopped corn dogs = 125, Salisbury steak = 130, cooked corn = 120, and plain hot dogs = 120. The cook did not remove any of the food items measured below 135 degrees from the steam table for reheating and continued to plate and serve food for residents onto the meal carts. On 4/25/23 at 11:48 a.m., the cook continued to plate food items including those below 135 degrees F onto plates for service to residents on the living units. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility failed to provide and/or follow physician orders for three of 23 residents (Resident #18, Resident #82, & Resident #97). The Findings Include: 1. Resident #18 did not have physician orders for the placement and care of an air cast. Diagnoses for Resident #18 included; Atrial fibrillation, diabetes, schizocarp disorder, fractured left ankle. The most current MDS (minimum data set) was a annual assessment with an ARD (assessment reference date) of 2/8/23. Resident #18 was assessed with a cognitive score of 15 out of 15 indicating cognitively intact. On 4/25/23 at 4:35 PM during an interview with Resident #18, an air cast was observed on the left ankle, when asked what happened, Resident #18 verbalized that she had fallen in her room and fractured her ankle. Resident #18 stated that the cast was placed at the hospital. Review of Resident #18's physician orders did not indicate orders were in place for the use or care of a air cast 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.

Based on observations, Group Interview, clinical record review, and staff interview, the facility failed to serve Lunch in a timely manner in the Main Dining Room, and failed to provide evening snacks on one of three nursing units, Unit A. During the Group Meeting, the residents complained about late meal service and the lack of snacks in the evening. The findings include: 1. At 11:30 a.m. on 4/25/2023, an observation of Lunch in the Main Dining Room was conducted. At the time of the observation, there were approximately 15 residents in the Dining Room. Staff in the Dining Room were passing drinks, tea, coffee, milk, soda, etc., to the residents as they waited for their Lunch. Kitchen staff were plating food and preparing trays for distribution to the three nursing units. The kitchen staff were clearly visible to the residents in the Dining Room. Only after the trays for the nursing units were prepared and sent to the units did the kitchen staff begin plating food for the residents in the Dining Room. At approximately 11:30 a.m., Resident # 76, who self-propelled in a Broda chair,…

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 implement their abuse policy for reporting and investigating injuries of unknown origin for one of 23 residents, Resident #69. Findings were: Resident #69 was admitted to the facility with the following diagnoses included but not limited to: Hypertension, Alzheimer's disease, unsteadiness on feet, conduct disorder, type II diabetes mellitus, anxiety, history of falling, and dementia. An annual MDS (minimum data set) with an ARD (assessment reference date) of 03/03/2023, assessed Resident #89 as severely impaired with a cognitive summary score of 00 out of 15. During initial tour of the facility on 04/25/2023 at approximately 11:15 a.m., Resident #69 was observed wandering in the hallway of the closed unit. Resident #69 did not respond when spoken to. The clinical record for Resident #69 was reviewed on 04/25/2023 at approximately 4:00 p.m. Review of the progress note section included a change of condition entry dated 03/04/2023 at 7:19 p.m. The note included 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 staff interview, clinical record review, and facility document review, the facility staff failed to report and thoroughly investigate injuries of unknown origin for one of 23 residents, Resident #69. Findings were: Resident #69 was admitted to the facility with the following diagnoses included but not limited to: Hypertension, Alzheimer's disease, unsteadiness on feet, conduct disorder, type II diabetes mellitus, anxiety, history of falling, and dementia. An annual MDS (minimum data set) with an ARD (assessment reference date) of 03/03/2023, assessed Resident #89 as severely impaired with a cognitive summary score of 00. During initial tour of the facility on 04/25/2023 at approximately 11:15 a.m., Resident #69 was observed wandering in the hallway of the closed unit. She did not respond when spoken to. The clinical record was reviewed on 04/25/2023 at approximately 4:00 p.m. Review of the progress note section included a change of condition entry dated 03/04/2023 at 7:19 p.m. The note included the following: Staff heard screaming by staff. Resident found by staff in other…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to thoroughly investigate injuries of unknown origin for one of 23 residents, Resident #69. Findings were: Resident #69 was admitted to the facility with the following diagnoses included but not limited to: Hypertension, Alzheimer's disease, unsteadiness on feet, conduct disorder, type II diabetes mellitus, anxiety, history of falling, and dementia. An annual MDS (minimum data set) with an ARD (assessment reference date) of 03/03/2023, assessed Resident #89 as severely impaired with a cognitive summary score of 00. During initial tour of the facility on 04/25/2023 at approximately 11:15 a.m., Resident #69 was observed wandering in the hallway of the closed unit. She did not respond when spoken to. The clinical record was reviewed on 04/25/2023 at approximately 4:00 p.m. Review of the progress note section included a change of condition entry dated 03/04/2023 at 7:19 p.m. The note included the following: Staff heard screaming by staff. Resident found by staff in other 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.

Based on staff interview and clinical record review, the facility failed to develop a care plan for two of 23 residents. Resident #18 did not have a care plan for the care of an air cast and Resident #76 did not have a care plan for activities. The Findings Include: 1. Diagnoses for Resident #18 included; Atrial fibrillation, diabetes, schizocarp disorder, fractured left ankle. The most current MDS (minimum data set) was a annual assessment with an ARD (assessment reference date) of 2/8/23. Resident #18 was assessed with a cognitive score of 15 out of 15 indicating cognitively intact. On 4/25/23 at 4:35 PM during an interview with Resident #18, an air cast was observed on the left ankle, when asked what happened, Resident #18 verbalized that she had fallen in her room and fractured her ankle. Resident #18 stated the cast was placed at the hospital. Review of Resident #18's care plan did not evidence a care plan had been put in place for the care of the air cast. On 4/26/23 at 11:54 AM registered nurse (RN #1, unit manager) was asked if a care plan should be developed regarding 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, staff interview and clinical record review, the facility staff failed to provide nail care for one of twenty-three residents in the survey sample (Resident #78) The findings include: Resident #78, assessed to require assistance with activities of daily living, was observed with long, broken fingernails and toenails. Resident #78 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), dysphagia, cognitive communication deficit, insomnia, schizophrenia, hypertension, and GERD (gastroesophageal reflux disease). The minimum data set (MDS) dated [DATE] assessed Resident #78 with moderately impaired cognitive skills and as requiring assistance of one person for personal hygiene. On 4/25/23 at 12:48 p.m., Resident #78 was interviewed about quality of care/life in the facility. Resident #78 was observed at this time with thick, long toenails on both feet. The big toenails extended approximately one-fourth inch beyond the end of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a medication was available for administration to one of twenty-three residents in the survey sample (Resident #97). The findings include: The medication oxycodone was not available for administration to Resident #97 as ordered. Resident #97 was admitted to the facility with diagnoses that included hip fracture, atherosclerotic heart disease, hypertension, gastroesophageal reflux disease, hypothyroidism, chronic respiratory failure, anxiety, depression, and diabetes. The admission nursing assessment dated [DATE] assessed Resident #97 as alert, oriented, with independent decision-making, and no memory problems. Resident #97's clinical record documented a physician's order upon admission on [DATE] for oxycodone 5 mg to be given every 6 hours as needed (prn) for pain management. The quantity ordered upon admission was for three doses. Resident #97's MAR documented doses were administered on 8/20/22 at 10:19 a.m., 8/20/22 at 8:34…

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 dental services for one of twenty-three residents in the survey sample (Resident #78). The findings include: Resident #78 was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), dysphagia, cognitive communication deficit, insomnia, schizophrenia, hypertension, and GERD (gastroesophageal reflux disease). The minimum data set (MDS) dated [DATE] assessed Resident #78 with moderately impaired cognitive skills. The annual MDS dated [DATE] documented that Resident #78 had no natural teeth. On 4/25/23 at 12:48 p.m., Resident #78 was interviewed about quality of life/care in the facility. When asked about any dental issues, Resident #78 stated that she had seen a dentist several months ago and was supposed to have work done for implants or dentures. Resident #78 was observed at this time with no upper or lower teeth. Resident #78 stated that she had 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.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure the menu provided met resident needs for one of 23 residents, Resident #82. Findings were: Resident #82 was admitted to the facility with the following diagnoses including but not limited to: hypertension, dementia, Alzheimer's disease, anxiety, localized edema, congestive heart failure, and cellulitis of her right and left lower limbs. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/22/2023 assessed Resident #82 as severely impaired with a cognitive summary score of 02 out of 15. On 04/25/2023, a meal observation was conducted during lunch on the closed unit of the facility. Resident #82's tray was observed. Her meal ticket/tray card contained the following: Regular-DYS ADV [dysphagia advanced] Chicken taco filling, flour tortilla, shredded lettuce, pureed cream style corn, pinto beans, sliced pears. Below that the ticket had the following entry: Main meal: Cook's choice: Corndog nuggets, mashed potatoes, pinto beans, bread, and pears. The food on…

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

Based on observations, clinical record review, and staff interview, the facility staff failed for one of 23 residents in the survey sample, Resident # 147, to provide an assistive device to enhance drinking ability. Resident # 147 was not provided with a specialized drinking cup, and was not provided assistance to prevent spillage while drinking. The findings were: Resident #147 was admitted with diagnoses that included epilepsy, left side hemiplegia, history of traumatic brain injury, depression, anxiety disorder, psoriasis, Vitamin D deficiency, anemia, and urinary urgency. Resident #147 was a new admission and the Initial (Admission) Minimum Date Set was not yet completed. According to the baseline care plan, dated 4/19/2023, Resident #147's cognitive status was listed as Confused. Resident #147's diet order was for a regular diet, pureed texture, with nectar thickened liquids. Under Activities of Daily Living, Resident #147 was noted to need the assist of two for bed mobility and transfer; and was dependent on staff for toileting, grooming/hygiene, and bathing. During…

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 provide dignity for one of twenty residents in the survey sample, Resident #53. Resident #53, without clothing and wearing only an incontinence brief was visible to other residents and staff on her living unit. The findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, COVID-19, myopia, anxiety, mood disorder, insomnia, cognitive communication deficit, major depressive disorder, gastroesophageal reflux disease, peptic ulcer disease, osteoarthritis and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #53 with severely impaired cognitive skills and as totally dependent upon staff for dressing and transfers. On 8/31/21 at 3:20 p.m., Resident #53 was observed in her room in a Broda specialized wheelchair with protective floor mats surrounding the chair. The resident had on no clothing other than an incontinence brief. Her upper body…

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 policy review and clinical record review, the facility staff failed to ensure privacy during personal care for one of twenty residents in the survey sample, Resident #50. Staff provided incontinence care for Resident #50 with the door open and no use of the privacy curtain. The findings include: Resident #50 was admitted to the facility on [DATE] with diagnoses that included pulmonary embolism, COVID-19, diabetes, bipolar disorder, chronic kidney disease, atrial fibrillation, hypertension, anemia and dysphagia. The minimum data set (MDS) dated [DATE] assessed Resident #50 as cognitively intact, frequently incontinent of bowel/bladder and requiring extensive assistance of two people for toileting and hygiene. On 9/1/21 at 10:25 a.m., certified nurses' aides (CNA #1 and CNA #2) were observed from the hallway providing incontinence care and a brief change for Resident #50. The door to the resident's room was open and there was no privacy curtain pulled around the bed.…

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 review and revise the comprehensive care plan for two of twenty residents in the survey sample, Resident #26 and #25. Resident #26's care plan was not revised with problems, goals and interventions regarding a significant weight loss. Resident #25's care plan was not revised to include non-drug interventions for pain. The findings include: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism, vitamin deficiency, bradycardia, polyneuropathy, gastroesophageal reflux disease, hypertension, history of myocardial infarction, cerebral infarction with dysphagia, COPD (chronic obstructive pulmonary disease), peripheral vascular disease, hemiplegia and COVID-19. The minimum data set (MDS) dated [DATE] assessed Resident #26 with severely impaired cognitive skills, requiring extensive assistance of one person for eating and having a significant weight loss of 5% or more in last month. 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, clinical record review, and staff interview, the facility staff failed to follow hospital discharge instructions for one of 20 residents in the survey sample, Resident 62. The facility failed to ensure Resident #62's hospital discharge orders/instructions to follow up with the resident's PCP (primary care physician) were followed. Findings include: Resident #62 was admitted to the facility on [DATE]. Diagnoses for Resident #62 included, but were not limited to: dementia, high blood pressure, chronic kidney disease, and hypothyroidism. The most current full MDS [minimum data set] assessment was an annual assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 3, indicating the resident had severe impairment in daily decision making skills. Resident #62 was observed multiple times throughout the survey process on 08/31/21 through 09/02/21. The resident was in her room, on the isolation (COVID) unit, in bed with bilateral knees drawn up toward her abdomen. The…

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

Based on a medication pass and pour observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure drugs and biologicals were labeled during a medication pass and pour observation for one of 4 residents in the medication pass, Resident #20. The facility failed to ensure Resident #20's insulin pen had a pharmacy label. Findings include: Resident #20 was admitted to the facility originally on 04/01/19. Diagnoses for Resident #20 included, but were not limited to: high blood pressure, anxiety, Alzheimer's dementia, hyponatremia, psychotic disorder, schizophrenia, and diabetes mellitus. The most current MDS (minimum data set) was a 5 day medicare assessment. This MDS assessed the resident with a cognitive score of 11, indicating the resident had moderate impairment in daily decision making skills. During a medication pass and pour observation on 09/01/21 at 8:15 AM, LPN (Licensed Practical Nurse]) #1 prepared medications for Resident #20. The medications included, but were not limited to: Levemir (insulin) FlexTouch Solution…

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 #6. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes, dementia with behavioral disturbance, hypertension, hyperlipidemia, muscle weakness, bipolar disorder, mood disorder, depression, and anxiety. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #6 as severely cognitively impaired for daily decision making with a score of 7 out of 15. On 09/01/2021, Resident #6's electronic clinical record was reviewed. Observed on the physician's order report were the following laboratory orders: Dilantin Q3 (every 3) months: Jan, Apr, July, Oct. Start Date: 8/16/2018. Depakote Q3 (every 3) months: Jan, Apr, July, Oct. Start Date 8/6/2018. A review of Resident #6's electronic clinical record did not include the July laboratory results 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 a medication pass and pour observation, staff interview, clinical record review and facility document review, the facility staff failed to to don gloves for insulin administration, and failed to perform appropriate hand washing after resident contact on one of three nursing wings, A wing (COVID 19 unit); and failed to follow infection control practices during incontinence care for one of 20 residents, Resident #50. Findings include: 1. During a medication pass and pour observation on 09/01/21 at 8:15 AM, LPN (Licensed Practical Nurse) #1 prepared medications for Resident #20. The medications included, but were not limited to: Levemir [insulin] FlexTouch Solution Pen-injector. LPN #1 adjusted the insulin pen to the prescribed number of units and took the prepared medications to the room of Resident #20. LPN #1 entered the room, went to the resident's bedside and administered the insulin in the resident's abdomen. LPN #1 did not have on gloves. LPN #1 administered the remainder of medications and then…

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 provide a privacy curtain for one of twenty residents in the survey sample, Resident #53. Resident #53's room had no suspended room curtain installed for privacy. The findings include: Resident #53 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, COVID-19, myopia, anxiety, mood disorder, insomnia, cognitive communication deficit, major depressive disorder, gastroesophageal reflux disease, peptic ulcer disease, osteoarthritis and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #53 with severely impaired cognitive skills and as totally dependent upon staff for dressing and transfers. On 8/31/21 at 3:20 p.m., Resident #53 was observed in her room in a specialized Broda wheelchair with protective floor mats surrounding the chair. The resident's roommate (Resident #28) was in bed at the time of the observation. There was no privacy curtain installed in 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 clinical record review, staff interview and facility document review the facility staff failed to correctly assess and document flu and pneumonia vaccine status for one of 5 records reviewed: Resident # 61. Resident # 61 was admitted to the facility 10/28/18 with a readmission date of 12/8/18 with diagnoses to include, but were not limited to: cognitive communication deficit, COPD, chronic respiratory failure, diabetes, and chronic kidney disease. The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 2/18/19 had Resident # 61 with moderate impairment in cognition with a total summary score of 07 out of 15. On 3/19/19 at 10:30 a.m. a review of Resident # 61's record revealed he was not offered pneumonia vaccine per the MDS admission assessment dated [DATE]. A quarterly MDS assessment dated [DATE] also documented the pneumonia vaccine was not offered. The information for the influenza vaccine, although resident admitted in October 2018, was not documented…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interview, the facility staff failed for one of 21 residents in the survey sample (Resident # 25) to ensure an accurate Minimum Data Set. Resident # 25 was identified on the most recent Quarterly Minimum Data Set as having a physical restraint. The findings were: Resident # 25 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included anemia, diabetes mellitus, anxiety disorder, depression, Gillain-Barre Syndrome, abdominal hernia without obstruction, generalized muscle weakness, dry eye syndrome, gastroesophageal reflux disease, Hypothyroidism, idiopathic progressive neuropathy, and acute kidney failure. According to the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/15/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section G (Functional Status), the resident was assessed as totally…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility staff failed to develop an initial care plan for one of 21 residents, Resident #184. Resident #184 did not have an initial care plan to address a feeding tube. The Findings Include: Resident #184 was admitted to the facility on [DATE]. Diagnoses for Resident #184 included: Skin Cancer of face receiving chemotherapy, CVA, traumatic brain injury, placement of feeding tube. The most current MDS (minimum data set) was an entry assessment with an ARD (assessment reference date) of 3/12/19. Resident #184 was not cognitively assessed at the time of the entry assessment. On 03/19/19 at 8:26 AM, Resident #184 was interviewed. During the interview Resident #184 verbalized that a feeding tube had been recently placed prior to being admitted to the facility. On 3/19/19 Resident #184's physician orders were reviewed and evidenced Resident #184 was to receive enteral feeding every 4 hours with a bolus of Osmolite. Resident #184's baseline care plan (dated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, and staff interview, the facility failed for one of 21 residents in the survey sample (Resident # 25) to develop a person centered plan of care with measurable goals and objectives to meet the resident's care needs. The facility failed to develop a plan of care to address Resident # 25's use of side rails. The findings were: Resident # 25 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included anemia, diabetes mellitus, anxiety disorder, depression, Guillain-Barre Syndrome, abdominal hernia without obstruction, generalized muscle weakness, dry eye syndrome, gastroesophageal reflux disease, Hypothyroidism, idiopathic progressive neuropathy, and acute kidney failure. According to the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/15/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section G…

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 in the course of a complaint investigation, facility staff failed to follow physician orders for one of 21 residents, Resident #285. Resident #285 was hospitalized from [DATE] through 10/04/2018. Upon her return to the facility, staff failed to correctly transcribe physician orders for Depakote. Resident #285 was ordered 750 mg of Depakote at bedtime. The orders were transcribed as 250 mg at bedtime. Resident #285 was under-medicated with her Depakote, which was ordered as a mood stabilizer. Findings were: Resident #285 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included but were to limited to: Anxiety disorder, paranoid schizophrenia, COPD (chronic obstructive pulmonary disease), heart disease, diabetes mellitus (type II), and hypertension. The significant MDS (minimum data set) assessment, with an ARD (assessment reference date) of 10/11/2018, assessed Resident #285 as cognitively intact with a summary…

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 in the course of a complaint investigation, facility staff failed to ensure dental services for one of 21 residents in the survey sample, Resident #334. Resident #334 did not receive any dental services while a resident in the facility. Findings included: Resident #334 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Dementia, Schizoaffective Disorder, Delusions, Bipolar Disorder, Insomnia, and Hypertension. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 05/24/2018. Resident #334 was assessed as severely impaired in his cognitive status with a total cognitive score of zero out of 15. Resident #334's clinical record was reviewed on 03/19/2019 at 1:00 p.m. A Nutrition Data assessment dated [DATE] included documentation that stated, .Oral Intake Conditions: Conditions Impacting Oral Intake .1b. Dental Problems . An annual MDS with an ARD of 08/17/2017 and a…

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, facility staff failed to ensure infection control practices during a dressing change for one of 21 Resident's, Resident #22. Proper hand hygiene was not performed during a wound dressing change. The Findings Include: Resident #22 was admitted to the facility on [DATE] with a readmission on [DATE]. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 1/17/19. Resident #22 was assessed as having long and short-term memory problems and assessed as being severely cognitively impaired. Diagnoses for Resident #22 included: Parkinson's disease, bilateral knee contractures, and unstageable pressure ulcers. On 03/19/19 at 12:55 PM, a dressing change was observed on Resident #22. Prior to the dressing change, certified nursing assistant (CNA) #1 was observed cleaning off the Resident's over-bed table with Clorox wipes, then threw the wipes and container in trash and pushed the container down into the trash can using…

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.