Westmoreland Rehabilitation & Healthcare Center

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 3 medication errors in 35 opportunities, resulting in an 8.57% error rate. The findings included: On 6/7/23 at 8:18 AM, Licensed Practical Nurse C (LPN C) and LPN D were observed during the medication administration of Resident #28. LPN C pulled Resident #28's medications which were a total of 10 pills (tablets and capsules). LPN C mentioned that they did not have the MiraLax to administer. LPN C said, it [MiraLax] has been out for several days- we have had hard time getting it from the pharmacy, it is out of stock. Since it is OTC [over the counter], supply has to order it. Following the medication administration, LPN C continued with her medication pass and did not make any attempts to clarify that a supply had/had not come in, notify the physician, or take any other actions. On 06/07/23 at 08:21 AM, LPN C and LPN D were observed during medication administration. LPN C entered the room and administered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation the facility staff failed to properly store medications for 1 of 2 medication carts inspected. The findings included: On [DATE] at 8:33 AM, while completing the medication storage tasks Surveyor E made the following observations of the medication cart for the 200 hall in the presence of LPN C and LPN D: 1. Resident #32 had a Lispro insulin pen that had an open date of [DATE], that was on the cart and available for use. Resident #32 also had a multi-use vial of Lantus, which had no date opened. 2. Resident #206, had an aspart insulin pen and a Degludec insulin pen that had no labeling for the date opened. 3. Resident #32 had a Basaglar Kwik pen in the cart, which did not have an open date. A Novolog insulin pen which had an open date of [DATE], remained in the cart and available for use. LPN C confirmed all of the above findings and confirmed the date opened on the ones that had a date and commented, They are only good for 28…

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, interview, clinical record review and facility documentation the facility staff failed to ensure the medical record was accurate for 1 Resident (#32) in a survey sample of 26 Residents. The findings included: For Resident #32 the facility staff failed to ensure that his clinical record contained only his information. On 6/8/23 when the electronic medical record was accessed for Resident #32 to view the Pre-admission Screening And Resident Review (PASARR) screening, a tab that said PASARR was clicked and what opened up was a document containing 33 PASARR's. Resident #32's PASARR was among the 33 PASARRs. On 6/8/23 at approximately 2PM, an interview was conducted with Employee N who was asked how assessments and records get put in the EHR (electronic health record), she stated that they are scanned and uploaded into the system. When asked if they do one chart at a time, she indicated that they did. When asked if a document is scanned into the wrong person's chart what happens, she stated that when they are aware of it, they immediately correct it. When asked why…

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 documentation review, the facility staff failed to determine the Resident's immunization status and offer influenza and pneumonia vaccines for 2 Residents (Resident #255 & #48) in a survey sample of 5 residents reviewed for immunizations. The findings include: 1. The facility staff failed to determine Resident #255's current immunization information and offer any immunizations the Resident was eligible. A clinical record review was performed on 6/7/23. Resident #255's clinical record revealed, under the immunization tab, that the flu vaccine and pneumococcal immunizations were, historical. The record had no information to support where the facility obtained this data. On 6/8/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #255 and verified the findings. The DON further confirmed there was no Virginia Immunization Information System (VIIS) uploaded into the record as evidence that the facility had attempted to obtain the Resident'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 staff interview, clinical record review and facility documentation review, the facility staff failed to offer COVID-19 immunizations for 2 Residents (Resident #255 and 48) in a survey sample of 5 Residents reviewed for COVID-19 immunizations. The findings include: 1. The facility staff failed to determine Resident #255's current immunization status and offer any COVID-19 immunizations the Resident was eligible for. A clinical record review was performed on 6/7/23. Resident #255's clinical record revealed, under the immunization tab, that the Resident had only received a primary vaccination series for COVID-19 and had not received any booster doses. Therefore, the Resident was eligible to receive the bivalent COVID-19 booster. On 6/8/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #255 and verified the above findings. The DON further confirmed there was no evidence that Resident #255 had received education or been offered the COVID-19 bivalent booster. 2. The facility staff failed to identify/assess…

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, employee record review and facility documentation review, the facility staff failed to operationalize policies and procedures on screening for 12 of 25 new employees in the Employee Records Check Sample. The findings include: 1. For Employees # 8, # 11, # 14, # 19 and # 24, the facility staff failed to ensure a criminal background check was obtained within 30 days of hire. On 2/17/2022 at 8:40 a.m., review of the employee files selected for Employee Records Check was conducted with the Human Resources Manager (Employee F) in her office. Review revealed the following: Employee # 8-Registered Nurse, Director of Nursing- hired 1/15/2020- Criminal Background Check on 7/8/2020 Employee # 11-Certified Nursing Assistant-hired 3/18/2020-Criminal Background Check on 7/8/2020 Employee # 14- Licensed Practical Nurse-hired 1/22/2020-Criminal Background Check on 7/8/2020 Employee # 19- Certified Nursing Assistant-hired 7/3/2019- No Criminal Background Check in employee file Employee # 24- Certified Nursing Assistant-hired 2/15/2020-No Criminal Background Check in…

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

Based on observation, Resident interview, staff interview, and facility documentation review, the facility staff failed to prepare the meal in accordance with the menu, which affected 52 of the 57 Residents, residing at the facility during survey. The findings included: On 2/15/22 at approximately 10:30 AM, a tour of the kitchen was conducted. This tour included an interview with the cook, Employee F. Employee F confirmed that he was preparing baked ziti as per the menu. On 2/15/22, the menu was reviewed which indicated the following items were to be served: Baked Ziti with meat sauce, broccoli florets, garlic breadstick, and cinnamon brown sugar blondie. The alternate meal was listed as: smothered turkey patty, Caesar salad, and mashed potatoes. On 2/15/22 at approximately 1:00 PM, the lunch meal tray line was observed by Surveyor D. Employee F, the cook, identified the items prepared as: baked ziti, broccoli florets, brownie and the alternate as a chicken patty and mashed potatoes. The preparation of trays was observed and no Residents were served a garlic break stick nor cinnamon…

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

Based on observation, Resident interview, staff interview, and in the course of a complaint investigation, the facility staff failed to provide Residents with food at an appetizing temperature for 3 Residents (Resident #21, #33, and #41) in a survey sample of 28 Residents. The findings included: On 2/15/22, during Resident interviews, Residents #41, #33 and #21 reported their hot foods are served cold frequently. On 2/15/22, Surveyor D requested a test tray be prepared during the lunch meal service. On 2/15/22 at 1:58 PM, the last Resident meal tray was delivered to a Resident. Administrative Employee D, the Registered Dietician, then retrieved the test tray from the meal cart and accompanied Surveyor D to a nutrition room on the unit to review the test tray. Both Administrative Employee D and Surveyor D tasted each food item on the tray and both confirmed that the baked ziti was room temperature and was not at an appetizing temperature. On 2/15/22, following the test tray observation, Administrative Employee D stated that she expect foods to be delivered in a manner so that cold…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and distribute food in accordance with professional standards for food service safety in 4 of 4 food storage and food preparation areas. The findings included: 1. The facility staff failed to store food in a manner consistent with professional standards for food service safety with regard to, labeling and protection from contaminates. On 2/15/22 at 10:30 AM, observations were made in the facility kitchen. The facilities dietary manager was not present during the survey, therefore Surveyor D was accompanied by Administrative Employee D, the registered dietician. In the dry storage room the following items were observed to be opened and not secured in a manner to protect from environmental contaminates: a bag of dry pasta ziti noodles and a bag of elbow macaroni dry pasta. Both bags were open to air, not secured and had no labeling to indicate when they were opened or to be used by. There was also a container of dry cereal that had been transferred out of its original…

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, facility documentation review, and clinical record review, the facility staff failed to maintain an infection control program in accordance with the Centers for Disease Control and Prevention (CDC) to prevent the spread of COVID-19 within the facility on 3 of 3 Resident halls within the facility. The findings included: 1. The facility staff failed to wear appropriate personal protective equipment (PPE) while providing care to a Resident (Resident #21) who was on quarantine for a COVID-19 exposure. On 2/15/22 at approximately 10:05 AM, Surveyor D observed CNA B enter the room of Resident #21. Prior to entering CNA B donned [put on] an isolation gown, face shield and gloves. CNA B was already wearing a procedure mask. There was a sign on the door that read, Special droplet contact precautions and indicated staff were to put on an N-95 mask, eye protection, isolation gown and gloves prior to entering the room. Upon exit, CNA B was interviewed and stated, I apologize, and I didn't put my N-95 on. On 2/15/22 at approximately 5 PM, Resident #21 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.

Based on observation, interview, facility documentation and clinical record review the facility staff failed to ensure Residents rights to a dignified existence for 1 Resident (#46) in a survey sample of 28 Residents. The findings included For Resident #46 the facility staff failed to answer a call bell in timely manner when Resident rang for pain and incontinence care. On 2/16/22 at approximately 1:05 PM Surveyor C entered the room of Resident #46 and found her in bed the sheets pulled away from the corners of the bed, she was dressed in a hospital gown and she stated I'm soaked honey and I'm hurting from my knees to my toes. When asked if she had called the nurse she stated I don't have a call bell. When asked if they had given her anything for pain she said Yes I didn't sleep well and they gave me Tylenol earlier but it doesn't help. The call bell was draped over the headboard out of the Resident's reach. The Resident was handed the call bell and she rang it. Surveyor C stepped into the hall and observed the following: At 1:14 PM - Resident began yelling out Please someone help…

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, Resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide reasonable accommodation to Residents who had paralysis for two (2) Residents (Resident #33 and #44) in a survey sample of 28 Residents. The facility staff failed to take into consideration the Residents' paralysis and inability to use one side, when placing the call bell so that they could call for assistance if needed. The findings included: 1. On 2/15/22 at 02:56 PM, Resident #33 was visited in his room. Resident #33 was lying in bed, left side paralysis was noted, which Resident #33 confirmed. The call bell was observed wrapped around the arm of a chair located on the left side of the bed past where the head of the bed was elevated and was out of reach. On 2/17/22 at 8:47 AM, Resident #33 was observed sitting in his wheelchair between his bed and the bed of the roommate, in the middle of the room. His hand bell that had been provided to summons staff in the event he needed assistance, was observed on the far side 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 interview, clinical record review and facility documentation the facility and in the course of a complaint investigation, staff failed to revise a care plan for 2 Residents ( #46 and #208) in a survey sample of 28 Residents. The findings included: 1. For Resident # 46 the facility failed to revise a care plan to include the need for psych services ordered in 11/8/21. Resident # 46 was admitted to the facility on [DATE], per her initial MDS (Minimum Data Set) she had a BIMS (Brief Interview of Mental Status) score of 9/15 indicating moderate cognitive impairment. Her most recent MDS dated [DATE] recorded the Resident as having a BIMS score of 7/15 indicating severe cognitive impairment. The MDS dated [DATE] Section E 0100 Psychosis - (Box B was checked) Delusions (misconceptions or beliefs that are firmly held contrary to reality). E 0200 Behavioral Symptoms - (Box B was checked) - Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) - 3…

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, interview, clinical record review, and facility documentation, the facility staff failed to provide proper ADL care for dependant Residents, for 2 Residents (#46 and #41) in a survey sample of 28 Residents. The findings included: 1. For Resident #46 the facility staff failed to provide timely incontinence care for Resident #46. On 2/16/22 at approximately 1:05 PM Surveyor C entered the room of Resident #46 and found her in bed the sheets pulled away from the corners of the bed, she was dressed in a hospital gown and she stated I'm soaked honey and I'm hurting from my knees to my toes. When asked if she had called the nurse she stated I don't have a call bell. The call bell was draped over the headboard out of the Resident's reach. The Resident was handed the call bell and she rang it. Surveyor C stepped into the hall and observed the following: At 1:14 PM - Resident began yelling out Please someone help me my legs hurt so badly. At !:18 PM - Employee J came in and asked if she needed help she stated that she was in pain and the Employee J stated she would let…

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, staff interview, facility documentation, and clinical record review, the facility staff failed to apply a hand splint to prevent the progression of contractures for one (1) Resident (Resident #27) in a survey sample of 28 Residents. The findings included: On 2/15/22 at 3:29 PM, Resident #27 sitting up in a Geri-chair (type of recliner chair) with a hand splint observed on her over bed table, not in use. Resident #27 was non-interviewable. On 2/16/22 at 8:18 AM, Resident #27 was observed lying in bed. The hand splint was noted to be on the over bed table, not in use. On 2/16/22 at 4:48 PM, Resident #27 was observed in bed, without a splint on. On 2/17/22 at 12:12 PM, Resident #27 was observed in bed, and did not have her splint on. A review of the clinical record for Resident #27 was performed. This review revealed a physician order dated 10/20/20, that read, Pt. [patient] to wear palm guard in left hand as tolerated. Review of the care plan for Resident #27 noted the following: A focus area initiated 8/5/2020, that read, I am at risk for pain due to impaired…

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

Based on staff interview and facility documentation review, the facility staff failed to ensure that competencies were completed for 1 of 5 sampled staff (LPN C). The Findings included: On 2-16-22, a review was conducted of employee records. The facility Director of Human Resources (Employee F) was interviewed. The employee training records were computer-based Relias training, and some paper copies of training which was conducted in the facility. Employee F utilized her computer to facilitate the review, and provided copies to surveyors. According to the Relias Computer System Course Completion History, and all paper copies of training in the facility, the facility failed to implement required training for LPN (C). LPN (C) was hired on 12-27-19. Review of training from 1-1-2021 through 12-31-21 showed no training for Infection Control. On 02/15/2022 LPN (C) was observed passing medications without any eye protection The Director of Human Resources was asked who was responsible for clinical staff training, and she stated that it was the nursing departments' responsibility to ensure…

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 interview, clinical record review and facility documentation the facility staff failed to provide behavioral heath services for 1 Resident (#46) in a survey sample of 28 Residents. The findings included: For Resident #46 the facility staff failed to obtain a consult for psych services when ordered on 11/8/21. Resident # 46 was admitted to the facility on [DATE], per her initial MDS (Minimum Data Set) she had a BIMS (Brief Interview of Mental Status) score of 9/15 indicating moderate cognitive impairment. Her most recent MDS dated [DATE] recorded the Resident as having a BIMS score of 7/15 indicating severe cognitive impairment. The MDS dated [DATE] Section E 0100 Psychosis - (Box B was checked) Delusions (misconceptions or beliefs that are firmly held contrary to reality). E0200 Behavioral Symptoms - (Box B was checked) - Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) - 3 -Behavior of this type occurred daily. A review 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.

Based on observation, interview and facility staff failed to store drugs appropriately in locked compartments for one of the two med carts at the facility. The findings included: 1. LPN C left several medications on the top of the cart while she went to the Resident's room to administer the medications. On 2/16/22 at approximately 8:30 AM while observing a Med Pass with LPN C, Surveyor C observed LPN C pull medications, place them in a medication cup, leave the medication cards on the top of the cart, and walking off to give the medications to a Resident. LPN D was at the nurses station and she was interviewed at that time and she was asked if it was usual practice to leave the medications on the top of the cart, she stated Oh no those meds should not be left on the cart ever. At approximately 8:35 AM Employee J the corporate RN was asked to look at the cart and she stated No meds should never be left unattended. She might have been nervous about being watched by a surveyor but still she shouldn't leave the meds on the cart. Per the facility Page 2 Medication Administration Policy :…

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

Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to accommodate meal preferences for two Residents (Resident #33 and #10) in a survey sample of 28 Residents. The findings included: On 2/15/22 at approximately 10:30 AM, a tour of the kitchen was conducted. This tour included an interview with the cook, Employee F. Employee F confirmed that he was preparing baked ziti as per the menu. On 2/15/22, the menu was reviewed which indicated the following items were to be served: Baked Ziti with meat sauce, broccoli florets, garlic breadstick, and cinnamon brown sugar blondie. The alternate meal was listed as: smothered turkey patty, Caesar salad, and mashed potatoes. On 2/15/22, the distribution of meal trays to Residents was observed. 1. Resident #33's meal ticket was noted to read, Baked Ziti with meat sauce, broccoli florets, garlic breadstick, cinnamon brown sugar blondie square, creamy peanut butter & jelly sandwich and fortified mashed potatoes. Resident #33 was observed to not have the garlic breadstick, a regular…

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

Based on observation, Resident interview, facility staff interview, and facility documentation review, the facility staff failed to ensure there was a functional system for Residents to call staff for assistance, for one Resident (Resident #33) in a survey sample of 28 Residents. The findings included: On 02/15/22 at 2:56 PM, during an interview with Resident #33, the Resident reported his call bell didn't work and had not for quite some time. Surveyor D engaged the call bell and noted that it did not light the indicator outside of the room. On 2/15/222, during the late afternoon, Surveyor D met with the Maintenance Director and requested a list of all pending maintenance work orders. On 02/16/22 at 8:57 AM, Surveyor D visited Resident #33 in his room. The call bell was pressed/engaged by the surveyor, and was noted to not be working. On 02/16/22 at 8:58 AM, an interview was conducted with RN A. RN A confirmed the call bell is engaged in the room, gives an auditory alarm, lights up out in the hall and has a notification at the desk. RN A further confirmed that call bells are used If…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility record review, the facility staff failed to provide personal privacy, and a dignified living experience for 9 of 13 Residents in the Resident council meeting. Residents complained of no privacy due to staff refusal to close personal bedroom doors, no private areas to meet with family and friends, staff refuse residents requests to make their own telephone calls, wandering residents enter rooms freely without supervision, and staff will talk about Residents medical needs out in the open around visitors and other residents. The findings included: On 2-6-19 at 2:00 p.m., A private posted Resident Council meeting was held with surveyors. There were 13 Residents in attendance. 9 of the 13 Residents were found to be alert, and oriented to person, place, time and situation, and were able to give accurate historical information, as supported and expounded upon by their peers. The council expressed the following concerns: 1. The Residents unanimously agreed that they…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. For Resident #39 the facility failed to develop and implement a person centered care plan to address behaviors related to refusing (Activities of Daily Living) ADL care. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On 2/5/2019 in the course of a complaint investigation, a clinical record review was conducted and it was found that Resident # 39 had a history of refusing ADL care. Nurse's notes dated 3/26/18 at 2:26 PM stating Bruise found on top of the right hand. Red blue in color. Self-inflicted due to fighting and hitting upon going to the bathroom or changing clothes RP notified and aware of situation MD notified. This note signed by LPN A Another progress note dated 5/17/2018 stated…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow the professional standards for the administration and documentation of medication administration in a timely manner for 3 Residents (Residents # 41, 53, and 27) in a survey sample of 27 residents. 1. For Resident #41, the facility staff failed to administer insulin in a timely manner on many days during the months of December, 2018 and January, 2019. 2. For Resident # 53, the facility staff failed to document the administration of multiple medications as ordered by the physician. 3. For Resident # 27, the facility staff failed to document the administration of multiple medications as ordered by the physician. The Findings included: 1. For Resident #41, the facility staff failed to administer insulin in a timely manner on many days during the months of December 2018 and January 2019. Resident #41 was a [AGE] year old who was admitted to the facility on [DATE].…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. For Resident #52, the facility staff failed to ensure that a significant medication error did not occur due to unavailable insulin for a period of 14 days. Resident #52 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #52's diagnoses included: Diabetes Mellitus Type Two, Hyperlipidemia, Dementia, Seizure Disorder, Traumatic Brain Injury, Anxiety Disorder, and Post Traumatic Stress Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 1/15/19, was reviewed. It coded Resident #52 as having a Brief Interview of Mental Status Score of 2, indicating severe cognitive impairment. On 2/6/19 a review was conducted of Resident #52's clinical record, revealing the following signed physician order, Bydureon Injection 2 MG subcutaneously one time a day every week on Monday. The Medication Administration Record for January, 2019 was reviewed. On Monday, 1/28/19 11:53 A.M. it read, Not Administered Drug item unavailable In addition, Resident #52's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to notify the physician of an unavailable diabetic management medication. For Resident #52, the facility staff failed to notify the physician of an unavailable diabetic management medication (Bydureon BCise auto-injector/insulin), resulting in the resident receiving the medication in 14 days, instead of 7 days, as per the signed physician order. The Findings included: Resident #52 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #52's diagnoses included: Diabetes Mellitus Type Two, Hyperlipidemia, Dementia, Seizure Disorder, Traumatic Brain Injury, Anxiety Disorder, and Post Traumatic Stress Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 1/15/19, was reviewed. It coded Resident #52 as having a Brief Interview of Mental Status Score of 2, indicating severe cognitive impairment. On 2/6/19 at 9:00 A.M., an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation and clinical record review the facility failed to provide a Medicaid/ Medicare Coverage Liability Notice for 1 Resident (Resident # 40) in a survey sample of 27 Residents. For Resident #4 the facility failed to provide Resident with a Medicaid/ Medicare Coverage Liability Notice prior to discharge. The findings include: Resident #40 a [AGE] year old woman was admitted to the facility with diagnoses of but not limited to Diabetes, Dementia, Atrial Fibrillation, Fracture of Femur, and (Urinary Tract Infection) UTI. Resident #40 had a (Brief Interview of Mental Status) BIMS score of 2 indicating severe cognitive impairment. She required physical assistance of 1 person with all aspects of (Activities of Daily Living) ADL care. On 02/07/2019 during the completion of facility tasks, the Administrator submitted the Medicaid/ Medicare Coverage Liability Notices and it was noted that one of the documents was not completed. On 02/07/2019, an interview was conducted with 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 2. For Resident #39 the facility failed to ensure freedom from verbal abuse by a staff member and being undressed and held down and made to shower after having refused on several occasions. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On [DATE] the facility provided their investigation of a complaint involving Resident #39. The complaint alleged the resident was physically abused by staff, forced to undress against her will and forced to shower against her will. The documents included witness statements made at the time of the incident. The facility submitted a file of documents from their investigation into the incident on [DATE]; included was a statement from CNA A stating [Resident #39 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 staff interview, facility documentation review, and clinical record review, and in the course of a complaint investigation, the facility staff failed to operationalize the abuse policy to include documentation of training after investigation of injuries of unknown origin for 1 residents (Resident # 55) in a survey sample of 27 residents. 1. For Resident # 55, the facility staff failed to report train the staff regarding proper transfers after investigation of an injury of unknown origin revealed a staff member used improper transfer resulting in fracture of her right ankle. The findings included: Resident # 55 was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses of but not limited to: Dementia, Hypertension, Deep Vein Thrombosis, and age-related Osteoporosis. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of [DATE]. The MDS coded Resident # 55 with severe cognitive impairment; Resident # 55 was coded as requiring…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility staff failed to report an allegation of abuse timely for Resident #13 in a survey sample of 27 residents. Resident #3 (male) willfully assaulted Resident #13 (female) on 9-4-18 and no report was sent to the state agency until 6 days later. All abuse reporting must be completed within 24 hours of the incident, or sooner. The findings included: Resident #13 was a female initially admitted to the facility on [DATE], with diagnoses including but not limited to; Dementia, cognitive communication deficit, hip pain, edema, dysphagia, folate deficiency anemia. The Resident was a Full Code status, meaning that CPR was requested to be performed as needed. The Resident was ambulatory and a known wanderer, with orders for a wanderguard bracelet to monitor the potential for elopement. The most recent Minimum Data Set Assessment (MDS) with an ARD (assessment reference 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 2. For Resident #39 the facility failed to submit an accurate complete investigation to the OLC and failed to provide additional training to all involved staff. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On [DATE] the facility provided their investigation of the complaint involving Resident #39. The complaint alleged the resident was physically abused by staff, forced to undress against her will and forced to shower against her will. Their documents included witness statements written at the time of the incident. The facility submitted a file of documents from their investigation into the incident on [DATE] included was a statement from CNA A stating [Resident #39 name] Shower day she didn't…

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, closed record review, and facility documentation, the facility staff failed to notify the ombudsman of transfer to hospital for one Resident (Resident #56) in a sample size of 27 residents. Because the resident was no longer at the facility, a closed record review was conducted. The findings included: Resident #56, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, depression, anxiety, dysphagia, muscle weakness, and history of femur fracture. Resident # 56's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/2018 was coded as a significant change in status assessment. The Brief Interview of Mental Status (BIMS) for Resident #56 was not coded but cognitive ability for daily decision-making was coded as severely impaired. Functional status for eating, dressing, toileting, and personal hygiene was coded as requiring extensive assistance from staff. Transfers between surfaces were coded as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, closed record review, and facility documentation, the facility staff failed to give notice of a bed hold when transferred to hospital for one Resident (Resident #56) in a sample size of 27 residents. Because the resident was no longer at the facility, a closed record review was conducted. The findings included: Resident #56, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, depression, anxiety, dysphagia, muscle weakness, and history of femur fracture. Resident # 56's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/2018 was coded as a significant change in status assessment. The Brief Interview of Mental Status (BIMS) for Resident #56 was not coded but cognitive ability for daily decision-making was coded as severely impaired. Functional status for eating, dressing, toileting, and personal hygiene was coded as requiring extensive assistance from staff. Transfers between surfaces were coded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to provide supervision to mitigate accident hazards for two resident in a survey sample of 27 residents. 1. For Resident # 55, the facility staff failed to transfer properly using two person assistance and gait belt as written in the care plan. 2. The facility staff failed to provide supervision, to include cueing and oversight for Resident #10 while she drank scalding hot chocolate. The findings included: 1. For Resident # 55, the facility staff failed to transfer properly using two person assistance and gait belt as written in the care plan. Resident # 55 was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses of but not limited to: Dementia, Hypertension, Deep Vein Thrombosis, and age-related Osteoporosis. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 5/21/18. The MDS coded Resident # 55 with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review the facility staff failed to ensure medication was available for use for 2 of 27 residents. 1. For Resident # 53, the facility staff failed to ensure medication was available for use. 2. For Resident #52, the facility staff failed to ensure that diabetic management medication was available for administration. The Findings Include: 1. For Resident # 53, the facility staff failed to ensure medication was available for use. Resident # 53 was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Gastrointestinal hemorrhage, Muscle Weakness, Multiple fractures of ribs, left side, Malignant neoplasm of bronchus or lung, Malignant neoplasm of Kidney, long term use of anticoagulants, chest pain, fracture of sternum and Dementia without behavioral disturbance. Resident # 53's most recent Minimum Data Set (MDS) was a 30 day assessment with an Assessment Reference Date (ARD) of 1/15/2019. The MDS coded…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to perform Medication Regimen Reviews for two Residents (# 53 and # 27) in a survey sample of 27 residents. 1. For Resident # 53, the facility staff failed to conduct a Monthly Medication Regimen Review in December 2018. 2. For Resident # 27, the facility staff failed to conduct a Monthly Medication Regimen Review in December 2018. Findings included: 1. For Resident # 53, the facility staff failed to conduct a Monthly Medication Regimen Review in December 2018. Resident # 53 was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Gastrointestinal hemorrhage, Muscle Weakness, Multiple fractures of ribs, left side, Malignant neoplasm of bronchus or lung, Malignant neoplasm of Kidney, long term use of anticoagulants, chest pain, fracture of sternum and Dementia without behavioral disturbance. Resident # 53's most recent Minimum Data…

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 documentation the facility failed to ensure that Residents were free from unnecessary psychotropic medication for 1 Residents (Resident #6) in a survey sample of 27 Residents. 1. For Resident #6 the facility failed to ensure the Resident had the appropriate diagnosis for receiving Anti-psychotic medications. The findings include: Resident # 6 is a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Dementia with behavioral disturbance, fracture of femur, Contracture of left hand, major depressive disorder single episode unspecified, Unspecified mood disorder. Resident #6's last two (minimum Data Set) MDS (screening tool) coded as Quarterly on 8/8/18 and Annual on 11/8/18, both coded the resident in section E-0100- Psychosis as Z. None of the above indicating that the Resident has had no Hallucinations or Delusions. Under section I Active Diagnosis - Psychiatric/Mood Disorders both MDS' coded her as NOT having…

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

Based on staff interview and facility documentation, the facility staff failed to date a multi-dose vial that had been accessed. The findings included: On 02/07/2019 at 11:45 AM, LPN A, the Corporate DON, and this surveyor entered the medication room by the central nurse's station. The medication refrigerator was unlocked by LPN A and the contents were inspected. A multi-dose vial of Influenza Vaccine was in an open box. The vial was removed from the box to note the vial's plastic top was removed, the rubber stopper appeared to be needle-punctured, and there was approximately 2 ml of clear medication in the vial. There was no writing on the vial to indicate when it was first opened. When asked about the policy for dating multi-dose vials, the corporate DON stated, It should be dated when opened. When asked how long a multi-dose vial is good for before it is discarded, the corporate DON stated, 30 days. When asked what will be done with this undated vial, the corporate DON stated, I will pull it and discard it. The facility policy General Guidelines for Medication Storage was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to serve hot chocolate at a safe temperature. The facility staff failed to ensure that Resident #10 was not served scalding hot chocolate. The Findings included: Resident #10 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #10's diagnoses included Gastro-esophageal Reflux Disease, Generalized Muscle Weakness, Other Chronic Pain, Inflammatory polyneuropathy, Functional dyspepsia, Sarcoidosis, Hypertension, Major Depressive Disorder, Hypokalemia, Heart Disease, and Diabetes Mellitus Type Two. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 8/11/18, coded Resident #10 as requiring the extensive assistance of two persons for bed mobility, transfers, and dressing. For eating, Resident #10 was coded as requiring supervision to include cueing and oversight. In addition, she was also coded as being on 2 opioid…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to obtain holding temperatures of breakfast and lunch food items on 2/5/19. In addition, facility staff failed to obtain hot water and coffee temperatures since January 2019. The Findings included: On 2/5/19 at 12:00 Noon, a review was conducted of the facility kitchen with the Dietary Manager (Employee E). The temperature logs were reviewed. The food temperatures had not been taken for the breakfast or lunch meals. In addition, coffee and hot water logs had not been done since January 2019. On 2/5/19, an interview was conducted with the Dietary Manager (Employee E). When asked if the hot liquid temperatures were ever taken, the Dietary Manager stated, Oh, it's always extremely hot. The Dietary Manager also stated that the cook (Employee D) had recorded the breakfast and lunch temperatures. The cook (Employee D) was next door in the dinning room. She was observed preparing and passing plates of food to the aides, who served the residents. When asked if she had taken the breakfast and…

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