Colonial Heights Rehabilitation And Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, it was determined that the facility staff failed to accommodate resident needs for four(4) of 33 residents in the survey sample, Resident #8, #19, #5 and #12. The findings include: 1. For Resident #8 (R8), the facility staff failed to maintain the call light in a position where they could access it. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/14/24, the resident was assessed as being severely impaired for making daily decisions. Section GG documented R8 having impairment one side of the upper extremity. On 12/19/24 at 8:54 a.m., an observation was made of R8 in their room. R8 was observed out of bed sitting in a wheelchair at the end of the bed between the footboard of the bed and the closet. The call bell was observed to be wrapped around the grab bar at the head of the bed out of R8's reach. On 12/20/24 at 8:26 a.m., an observation was made of R8 in their room. R8 was observed 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 resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the requirements for a resident room change for four (4) of 33 residents in the survey sample, Resident #25 (R25), R26, R27, and R28. The findings include: 1. For R25, the facility staff failed to provide the resident with written notification of a room change, the opportunity to see the new location and meet the new roommate, when the R25 was transferred to a different room on 12/22/2024 and on 12/26/2024. On 12/31/2024 at approximately 8:55 a.m., an interview was conducted with R25. When asked why he had a room change R25 stated that he was told by the facility staff that it was for consolidating residents. When asked how long it was from being informed of the room change until he was moved R25 stated the first move was within two hours of being told and the other move R25 stated the staff came into his room told him he was being moved and immediately move him. When asked…

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, it was determined that the facility staff failed to notify the physician and/or responsible party of a change in condition for four of 33 residents in the survey sample, Resident #8, #16, #1 and #4. The findings include: 1. For Resident #8 (R8), the facility staff failed to notify the physician of medications not administered on 9/24/24, 9/28/24, 11/17/24, and 11/23/24. Review of the eMAR (electronic medication administration record) dated 9/1/24-9/30/24 for R8 documented the resident not receiving Aricept 10mg 2 tablets at 4:00 p.m. and Atorvastatin 20mg at 8:00 p.m. on 9/24/24, and Memantine 10mg at 5:00 p.m. on 9/28/24. The eMAR documented a chart code of Other/See Progress Notes. Review of the eMAR dated 11/1/24-11/30/24 for R8 documented the resident not receiving Glucosamine 1500 and Namenda 10mg at 9:00 a.m. on 11/17/24. The chart codes documented Hold/See Nurses Notes. The eMAR further documented R8 not receiving Sertraline…

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, interviews and clinical record reviews, the facility staff failed to ensure a clean comfortable homelike environment on two of three facility units, [NAME] and [NAME]. The findings include: 1. For one of four hallways on the [NAME] unit, the facility staff failed to maintain a homelike environment. On 12/19/24 at 8:16 a.m., an observation of the [NAME] unit was conducted. Observation of the 114-124 hallway revealed a strong, musty odor lingering in the hallway between rooms 119-124. Additional observations on 12/19/24 at 9:01 a.m., 11:09 a.m., and 12:10 p.m. revealed the findings above. On 12/19/24 at 12:45 p.m., an interview was conducted with OSM (other staff member) #10, the director of environmental services. OSM #10 stated that they had two housekeepers who worked on the [NAME] unit. She stated that the resident rooms were cleaned daily and to control odors they used a spray air freshener product that pulled odors out of the air and cleaned the mattresses when the CNA (certified…

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, it was determined that the facility failed to protect four (4) of 33 residents in the survey sample from resident-to-resident abuse, Residents #33, #30, #18 and #9. The findings include: 1. For Resident #33 (R33), the facility staff failed to ensure that they were free from abuse from Resident #9 (R9) during a resident-to-resident incident on 8/14/24. On R33's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 9/21/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The prior MDS with an ARD of 6/21/24 documented a score of 15 out of 15 on the BIMS assessment also. Review of a facility synopsis of events dated 8/14/24 for R33 documented a resident-to-resident incident between R33 and Resident #9 (R9). It documented in part, Residents observed in activity…

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 #33 (R33), the facility staff failed to implement their abuse policy to ensure R33 was free of abuse from Resident #9 (R9) and complete and thorough investigation of a resident-to-resident altercation on 8/14/24. On R33's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 9/21/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The prior MDS with an ARD of 6/21/24 documented a score of 15 out of 15 on the BIMS assessment also. Review of a facility synopsis of events dated 8/14/24 for R33 documented a resident-to-resident incident between R33 and Resident #9 (R9). It documented in part, Residents observed in activity event and had an incident. Residents immediately separated . The investigation folder contained a five-day investigation summary dated 8/20/24 and a typed witness statement signed by the former administrator on 8/14/24. 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 8. For Resident #5 (R5), the facility staff failed to implement the comprehensive care plan to administer medications as ordered. The comprehensive care plan for R5 documented in part, - Antipsychotics: the resident is at risk for adverse reactions related to the use of antipsychotics secondary to diagnosis of schizophrenia. Created on: 09/26/2023. Revision on: 01/23/2024. Under Interventions it documented in part, administer medications as ordered. Date Initiated: 09/26/2023. Created on: 09/26/2023. Revision on: 01/23/2024 . - Medications: the resident is at risk for complications related to psychoactive medication use secondary to diagnoses of insomnia. Created on: 10/04/2023. Revision on: 05/02/2024. Under Interventions it documented in part, administer medications as ordered. Date Initiated: 10/04/2023. Created on: 10/04/2023. Revision on: 05/02/2024 . - Anticoagulant: the resident is at risk for bleeding, hemorrhage, excessive bruising and complications related to anticoagulant use for prophylaxis. Created…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to follow professional standards of practice for four (4) of 33 residents in the survey sample, Residents #1, #23, #5 and #3. The findings include: 1. For Resident #1, the nurse failed to document an assessment on 10/1/24 of the resident's skin. An interview was conducted with LPN (licensed practical nurse) #3 on 12/19/24 at 10:09 a.m. LPN #3 stated she was called on 10/1/24 to assess R1's skin. She stated it, It wasn't a wound. It was severe bruising that was spreading. Apparently, the bruise was reported to the doctor that the bruising was in the peri area. The bruising was not there when the wound nurse practitioner saw her on 9/27/24. The other nurse (not available for interview) was the first to see the bruise. I was pulled off the medication cart to see it. I saw purple discoloration. The pubis was purplish in color, and it moved to the buttocks. It was deep purple…

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 #21 (R21), the facility staff failed to provide showers at least twice a week per the resident's preferences. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/18/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. Section GG documented R21 requiring substantial to maximal assistance with showering/bathing. On 12/20/24 at 10:36 a.m., an interview was conducted with R21 in their room. R21 stated that they had only had about three showers since their admission. She stated that on admission she was wearing a neck brace and was not allowed to take it off until the doctor cleared her later in October. R21 stated that getting a shower was like pulling teeth in the facility. She stated that the showers were supposed to be twice a week, but the staff always said they would be back to get them for the shower and never came back. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services per the physician orders for five of 33 residents in the survey sample, Residents #1, #4, #23, #21, and #16. The findings include: 1. For Resident #1 (R1), the facility failed to administer medications per the physician orders. The physician orders documented: 1. Famotidine Tablet (1) 20 MG (milligrams); Give 20 mg by mouth one time a day related to GASTGROESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS. 2. MONTELUKAST TAB (Tablet) (2) 10 MG; Give 1 tablet orally in the evening for allergies. 3. Novolin N Suspension NPH (3) - Inject 24 units subcutaneously in the evening for DM (diabetes mellitus) notify MD (medical doctor) of BS (blood sugar < (less than) 60 or > (greater than) 400. 4. Novolin N Suspension NPH - Inject 55 units subcutaneously in the morning for DIABETES MELLITUS WITHOUT COMPLICATIONS. 5. Omeprazole Cap (Capsule) (4); Give 1…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services for pressure injuries for four of 33 residents in the survey sample, Residents #1, #17, #13 and #14. The findings include: 1. For Resident #1, the facility staff failed to administer the physician prescribed treatments to prevent pressure injuries. The physician order dated, 4/10/24, documented, SACRUM: BARRIER CREAM: every shift for skin integrity. The September TAR (treatment administration record) documented the above order. There were blanks on the TAR on the following dates and shifts: 9/2/24 - evening shift 9/4/24 - evening shift 9/6/24 - night shift 9/7/24 - evening and night shift. 9/28/24 - evening shift. The physician order dated 5/13/24, documented, L (Left) BUTTOCK: Cleanse the area with NS (normal Saline), pat dry, apply LIQUID MEDI HONEY (1) and cover with silicone border dressing every evening shift. The September TAR documented 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 employee record review, staff interview and facility document review, it was determined that the facility staff failed to ensure that four out of 10 CNA (certified nursing assistant) records reviewed evidenced training that included the required abuse and neglect, dementia, resident rights, infection control, communication, and/or behavioral health. The findings include: On [DATE] at 2:00 p.m., a review of a sample of five facility CNAs and five agency CNAs were reviewed for evidence of required training. 1. Review of CNA #5's agency employee record documented a current license, background check and sworn statement. The file failed to evidence education for abuse and neglect, dementia, resident rights, infection control, communication, and behavioral health. 2. Review of CNA #6's agency employee record documented a current license, background check dated [DATE] and sworn statement. The file failed to evidence education for communication and behavioral health. 3. For CNA #7, no agency file was provided.…

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, and facility document review, it was determined that facility staff failed to obtain physician ordered laboratory tests for two of 33 residents in the survey sample, Residents #16 (R16) and R4. The findings include: 1. For R16, the facility staff failed to obtain physician ordered laboratory (lab) tests of CBC (complete blood count) (1), BMP (basic metabolic panel) (2) and CRP (C-Reactive protein) (3) on 10/07/2024, 10/14/2024, 10/21/2024 and 10/28/2024; a CBC on 11/21/2024; and a CBC and CMP (comprehensive metabolic panel) (4) ordered on 12/05/2024 for two days. R16 was admitted to the facility with diagnoses that included but were not limited to osteomyelitis (5) of vertebra (bone of the spine), sacral (bottom of the spine) and sacrococcygeal region (base of the spine) and sepsis (6). On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 10/10/2024, R16 scored 13 out of 15 on the BIMS (brief interview for mental status), indicating R16 was cognitively…

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, it was determined that the facility staff failed to serve palatable food for one of three facility units, [NAME] Unit. The findings include: On 12/18/2024 at t approximately 1:05 p.m. a test tray consisting of mixed vegetables, gravy, mashed potatoes, pasta with sauce and sliced turkey breast and were placed in a food cart, sent to the [NAME] unit. The cart was followed by this and another surveyor, OSM (other staff member) #35, kitchen supervisor. At approximately 1:25 p.m., the last lunch tray was served to a resident on the [NAME] unit and OSM #35 was asked to remove the test tray from the food cart, then proceeded to take the temperatures of the food. All the food was 140 degrees F (Fahrenheit) or greater. The test tray was sampled by two surveyors and OSM #35 for palatability, however, OSM #35 would not taste the turkey breast stating she did not like turkey. After tasting the turkey breast by the surveyors, it was agreed that it had a gelatinous taste. On…

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

Based on observation, staff interview, and facility document review it was determined facility staff failed to store, prepare, and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 12/18/2024 at approximately 9:00 a.m., an observation of the facility's kitchen revealed the following: 1. Observation of the inside of the walk-in refrigerator revealed a quarter of a whole ham sitting on the second shelf up from the floor partially uncovered. 2. Observation of the inside of the facility's reach-in refrigerator at approximately 9:00 a.m., located in the facility's kitchen, revealed containers of juice and iced teas. Observation of the thermometer inside the reach-in refrigerator indicated an internal temperature of 56 degrees. Another observation of the thermometer inside the reach-in refrigerator at 12:05 p.m., indicated an internal temperature of 51 degrees. 3. Observation of the tray line in the facility's kitchen revealed OSM (other staff member) #36, dietary aide, standing at the end of the tray line, checking the resident's meal trays 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 resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to act upon a reported grievance in a timely manner, for two (2) of 33 residents in the survey sample, Resident #21 and Resident #5. The findings include: 1. For Resident #21 (R21), the facility staff failed to respond to a reported grievance in a timely manner and provide a written response regarding the grievance. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/18/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 12/20/24 at 10:36 a.m., an interview was conducted with R21. R21 stated that they had filed multiple grievances with the social worker about care concerns, environmental concerns and food concerns and had not received any follow up. She stated that all she had heard was that education was provided to the staff which had not changed anything for very…

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

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to report an injury of unknown origin for one (1) of 33 residents (Resident #8) in the survey sample. The findings include: For Resident #8 (R8), the facility staff failed to report an injury of unknown origin reported to staff by family on 6/17/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/14/24, the resident was assessed as being severely impaired for making daily decisions. Section GG documented R8 having impairment one side of the upper extremity. The progress notes for R8 documented in part: - 06/14/2024 19:32 (7:32 p.m.) Late Entry. Medical Note. patient doing well no new complaints .Extremities no cyanosis no clubbing or edema . - 06/17/2024 17:05 (5:05 p.m.) Late Entry. Note Text: Family made writer aware that after home visit one Sunday, resident was seen holding right wrist and not allowing anyone to touch it. NP (nurse practitioner) was made aware and stated she would see him 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 clinical record review, staff interview and facility document review, it was determined that the facility staff failed to fully investigate an allegation of abuse and/or injury of unknown origin for three (3) of 33 residents, Resident #33, #8 and #1. The findings include: 1. For Resident #33 (R33), the facility staff failed to ensure a complete and thorough investigation of a resident-to-resident altercation on 8/14/24. Review of a facility synopsis of events dated 8/14/24 for R33 documented a resident-to-resident altercation between R33 and Resident #9 (R9). It documented in part, Residents observed in activity event and had an altercation. Residents immediately separated . The investigation folder contained a five-day investigation summary dated 8/20/24 and a typed witness statement signed by the former administrator on 8/14/24. The progress notes for R33 documented in part, - 08/15/2024 15:03 (3:03 p.m.) Social Services. Note Text: SW (social worker) met with resident 1:1 to assess psychosocial…

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 document review and clinical record review, it was determined the facility staff failed to provide care and services for a feeding tube for one of 33 residents in the survey sample, Resident #13. The findings include: For Resident #13 (R13), the facility staff failed to change a dressing around the feeding tube insertion site per the physician order. Observation was made on 12/30/24 at 1:45 p.m. of R13, accompanied by CNA (certified nursing assistant) #35. The dressing around the insertion site of the tube feeding tube was dated 12/28/24. This was verified by the CNA #35. The physician order dated, 6/23/24, documented, Enteral Feed Order: Every day shift change split gauze. The November 2024 TAR (treatment administration record) documented the above order. On 10/26/24, there was a blank where it should be documented the treatment was completed. The December 2024 TAR documented the above order. On 12/9/24 and 12/18/24, there were blanks where it should be documented the treatment was completed. On 12/29/24, the nurse initialed that 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, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to store a nebulizer mouthpiece in a sanitary manner for one of 33 residents in the survey sample, Resident #11. The findings include: For Resident #11 (R11), the facility staff failed to store a nebulizer mouthpiece in a sanitary manner. Observation was made of R11 on 12/19/24 at 3:43 p.m. The nebulizer mouthpiece was lying on her nightstand. R11 stated she uses her nebulizer at times when she can't breathe. A second observation was made on 12/20/24 at 7:55 a.m., the nebulizer mouthpiece was still uncovered. On 12/30/24 at 10:36 a.m. The nebulizer mouthpiece was attached to the nebulizer machine, not covered in any manner. The physician order dated, 10/10/24, documented, Ipratropium - Albuterol Solution 0.5 - 2.5 (3) MG/3 ML (milligrams per 3 milliliters); 3 ml inhale orally every 4 hours as needed for SOB (shortness of breath) or Wheezing via nebulizer. An interview was conducted with LPN (licensed practical nurse) #1 on 1/2/25…

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, clinical record review, staff interview and facility document review it was determined that the facility staff failed to provide a complete pain management program for one (1) of 33 residents in the survey sample, Resident #21. The findings include: For Resident #21 (R21), the facility staff failed to obtain prescribed pain medication Hydromorphone (1) in a timely manner. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/18/24, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section J documented R21 receiving scheduled and as needed pain medications and having frequent pain. On 12/30/24 at 10:36 a.m., an interview was conducted with R21 who stated that the facility ran out of their pain medication over Christmas. She stated that she went five days with none of the as needed pain medication and she was told that there was no physician to sign a prescription for 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 interview, facility document review and clinical record review, it was determined the facility staff failed to ensure medications were available for administration for three (3) of 33 residents in the survey sample, Residents #1, #4, and #21. The findings include: 1. For Resident #1 (R1), the facility staff failed to ensure Paxlovid (1) was available for administration. It was not started until six days after the physician order. The physician order dated 8/30/24, documented, Paxlovid (150/100) oral tablet therapy pack 10 x 150 MG (milligrams) & 10 x 100 MG; give 1 tablet by mouth one time a day for antiviral for 10 days use as directed. The pharmacy delivery manifest documented the Paxlovid was delivered on 9/6/24 at 6:18 a.m. The September 2024 MAR (medication administration record) documented the above order. On 9/1/24, 9/2/24, and 9/4/24 the nurses documented administering the dose at 8:00 a.m. On 9/3/24 and 9/5/24, there was a 9 documented. A 9 indicated, Other/See Progress note. The progress note dated, 9/3/24 at 2:13 p.m. documented, Awaiting pharmacy. 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 interview, facility document review, and clinical record review, it was determined the facility staff failed to maintain an accurate clinical record for three (3) of 33 residents in the survey sample, Residents #1, #4 and #13. The findings include: 1. For Resident #1, the facility staff documented the medication, Paxlovid, was given when the medication was not available from the pharmacy for administration. The physician order dated 8/30/24, documented, Paxlovid (150/100) oral tablet therapy pack 10 x 150 MG (milligrams) & 10 x 100 MG; give 1 tablet by mouth one time a day for antiviral for 10 days use as directed. The pharmacy delivery manifest documented the Paxlovid was delivered to the unit on 9/6/24 at 6:18 a.m. The September 2024 MAR (medication administration record) documented the above order. On 9/1/24, 9/2/24, and 9/4/24 the nurses documented administering the dose at 8:00 a.m. when the medication had not been delivered to the facility. An interview was conducted with LPN (licensed practical nurse) #1, on 1/2/25 at 10:10 a.m. When asked how a nurse confirms…

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, staff and resident interviews, clinical record reviews, and facility documentation, the facility staff failed to ensure the facility was free of pests. The findings included: During the lunch meal on 12/23/24, room [ROOM NUMBER]'s B bed Cove Base Molding was observed from the hallway to have fallen entirely from the wall and floor transition with prominent crumbled sheetrock on the floor along the entire length of the Cove Base Molding. The resident in the B bed (R#26) sat in a wheelchair, eating lunch next to the outside back wall with the dismantled sheetrock to his right side and in the pathway of his wheelchair. Resident #26 did not respond verbally when asked what he thought about the condition of the wall he was sitting next to; he just smiled and placed his hands in the air. An unidentified light brown bug approximately three inches long with too numerous to count legs on each side and long tentacles was observed crawling on the crumbled sheetrock. Resident #26 was admitted 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 staff interview, clinical record review, and facility documentation review, the facility staff failed to follow standards of practice affecting 7 residents (Resident # 4, #12. #14, # 2, #21, #18, & #9 ) in a survey sample of 23 residents. The findings included: 1. For Resident # 4, the facility staff failed to take blood pressures prior to the administration of the medication Midodrine Resident # 4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Chronic Obstructive Pulmonary Disease, Emphysema, Diabetes and Rhabdomyolisis. The most recent MDS (Minimum Data Set) assessment was coded as a quarterly assessment with an ARD (Assessment Reference Date) of 6/15/2024. The BIMS (brief interview for mental status) was coded as 12 out of possible 15 indicating moderate cognitive impairment. Review of the clinical record was conducted on 7/30/2024 to 8/6/2024. Midodrine HCl Tablet 10 MG (milligrams) Give 1 tablet by mouth three times a day for hypotension HOLD FOR SBP…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, clinical record review, the facility staff failed to ensure incontinence care was provided timely for 1 resident (Resident # 12) in a survey sample of 24 residents. The Findings Included: For Resident #12, the facility staff did not provide timely incontinence care. For Resident # 12, the facility staff failed to identify a severe yeast rash on the buttocks and thigh that was identified by the nurse practitioner and failed to provide incontinence care to meet the needs of Resident # 12. Resident # 12 was admitted to the facility on [DATE] with diagnoses that included but were not limited to COPD (Chronic Obstructive Pulmonary Disease), Diabetes, Hypertension, Pulmonary Embolism, and VRE (Vancomycin Resistant Enterococcus) of urine. Resident # 12 was discharged to home with family on 7/26/2024. The most recent MDS (Minimum Data Set) assessment was coded as a quarterly assessment with an ARD (Assessment Reference Date) of 7/20/2024. The BIMS (brief interview 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 staff interview, facility documentation review and clinical record review, the facility staff failed to ensure three Residents (Resident #14, #4 and #21) of 23 residents in the survey sample were free of significant medication errors. The findings included: 1. For Resident # 14, the facility staff failed to ensure the medication, Trulicity, was available for administration as per physician orders. Resident # 14 was admitted to the facility in 2018 with diagnoses that included but were not limited to: Diabetes, Cerebral Palsy, Dysphagia, Contracture and Hypertension. The most recent MDS (Minimum Data Set) assessment was coded as an annual assessment with an ARD (Assessment Reference Date) of 6/14/2024. The BIMS (brief interview for mental status) was coded as 15 out of possible 15 indicating no cognitive impairment. Resident # 14's clinical record was reviewed 7/31/2024-8/6/2024. Review of the Physicians Orders revealed a Physician's order for the medication: Trulicity 0.5 milliliters subcutaneously one…

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 staff failed to obtain laboratory specimens as ordered and notify the physician of the delay in obtaining the specimens for 1 Resident (#9) in a survey sample of 23 residents. The findings included: Resident #9 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, diabetes, cognitive communicative deficit, Dementia, Alzheimer's, Aphasia, and History of falling. Resident #9 was discharged home on [DATE]. Resident #9's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 06/03/2024 was a discharge assessment. The MDS coded Resident #9 with a BIMS (Brief Interview for Mental Status) score of 3 out of 15 possible points, indicating server cognitive impairment. On 07/30/2024, at approximately 2:00 pm, an interview was conducted with Regional Nurse Consultant and the Director of Nursing (DON). The DON was asked what is expected when labs are ordered by the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation the facility staff failed to consult with the resident's physician, and notify, the resident representative when there is a change in physical, mental or psychosocial status for 1 Resident (#20) in a survey sample of 23 Residents. The findings included: For Resident #20 the facility staff failed to notify the physician and the resident representative of being found engaging in sexual activity with another resident on 2 occasions. Resident #20 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified sequelae of Cerebral Infarction, (unspecified changes brought on by stroke they can vary from physical changes to personality changes), bipolar disorder current episodic hypomanic, alcohol abuse, cocaine use, metabolic encephalopathy, Sexual dysfunction not due to substance or known physiological condition, generalized anxiety disorder, hypertension, major depressive disorder and history of breast…

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 implement the abuse policy for 1 Resident, (#20), in a survey sample of 23 Residents. The findings included: For Resident # 20 facility staff failed to notify the Responsible party of discovery that the Resident was allegedly having consensual sexual contact with another Resident (#19). A review of Resident #20's clinical record revealed that Resident #20 was admitted to the facility on [DATE], with diagnoses that included but were not limited to, generalized anxiety disorder, major depressive disorder, bipolar disorder, hx (history) of alcohol abuse, hx of cocaine use, COPD, hx of cerebral infarction and sexual dysfunction not due to a substance or known physiological condition. A review of Resident #20's care plan revealed the following: FOCUS: Resident has behaviors noted to make sexual advances towards staff, observed with a cigarette in her mouth in facility, noted to have sexual advances towards male…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to complete a 48-hour baseline Care Plan for one Resident (Resident #18) in a survey sample of 23 Residents. The findings include: For Resident #18, the facility staff failed to develop and implement a 48-hour baseline care plan to include guidance for effective person-centered care. For Resident #18, the facility staff failed to provide focus, goals, and interventions regarding urinary retention, and self-catheterization. Resident #18 was admitted to the facility on [DATE], with diagnoses including but not limited to; urinary tract infection, urine retention, benign prostate hyperplasia (BPH), type 2 diabetes, hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, muscle weakness, and personal history of transient cerebral infarct (TIA). Resident #18's MDS review included the MDS (Minimum Data Set Assessment) with an ARD (Assessment…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Resident interviews, staff interviews, and facility documentation review, the facility staff failed to act promptly to Resident grievances in July 2022 and August 2022. The findings included: The facility staff failed to evidence a resolution to concerns raised by residents about call device response times in the July and August 2022 Resident Council meetings. According to Resident #93's quarterly Minimum Data Set with an Assessment Reference Date of 08/31/2022, the Brief Interview for Mental Status was coded as 13 out of possible 15 indicative of intact cognition. On 10/25/2022 at approximately 1:15 P.M., Resident #93 was interviewed. When asked about the timeliness of call devices being answered, Resident #93 stated that sometimes they wait an hour or two for staff to answer the call device. Resident #93 stated that it is not convenient to get into the wheelchair but will sometimes have to get up into their wheelchair and go looking for staff. On 10/26/2022, the Resident Council minutes from July 2022…

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, staff interviews and facility documentation review, the facility staff failed to ensure that expired medications were discarded on one of two medication carts on the [NAME] unit, and in one of three medication storage rooms, the [NAME] unit medication room. The findings included: 1. The facility staff had available for administration, multiple medications that were expired on 1 medication cart on the [NAME] unit. On 10/27/22 at approximately 9 AM, LPN (licensed practical nurse) D was during an inspection of the 200 hall medication cart #2. The following medications, all of which were expired, were in the cart, available for administration: Liquid pain relief 160mg/5 ml, 16 oz., which expired 6/2022; Bottles of Zinc 50 mg which expired 08/2022; Aspirin 325 mg which expired 9/2022; Vitamin B complex which expired 9/2022; A vial of Humulin 70/30 insulin which was labeled as being opened on 9/13/22. LPN D confirmed that insulin is to be used within 30 days of when opened. When asked why, she…

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 one of one kitchen inspected. 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 10/25/22 at 11:45 AM, observations were made in the facility kitchen. The facility's dietary manager was present. On a cart on the outside of the walk-in freezer, a bag of open, undated oatmeal was present. The dietary manager said, We have to date items when opened and when it comes in, so we know we are serving right things to Residents, and she threw away the oatmeal. In the dry storage room a bag of rice was open and not secured in a manner to protect from environmental contaminates. The bag was open to air, not secured, and had no labeling to indicate when it was opened or to be used. The dietary manager said, We have to know when it is opened…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, Resident interview, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to maintain an effective pest control program to mitigate the presence of pests on for one of 55 residents in the survey sample, Resident #195; and in three out of three units of the facility in October 2022. The findings included: The facility staff failed to follow the recommendations of the pest control company on 10/19/2022 and 10/26/2022 to mitigate the ongoing presence of pests. According to Resident #195's admission Minimum Data Set with an Assessment Reference Date of 10/09/2022, the Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition. On 10/26/2022 at approximately 9:30 A.M., Resident #195 was interviewed. When asked about pests, Resident #195 stated that there are flies in her room and stated that she saw one that morning. Resident #195 was finished eating breakfast but the breakfast tray 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, and clinical record review, the facility staff failed to communicate the Resident's choice for advanced directives for one Resident (Resident #396) in a sample size of 55 Residents. The findings included: For Resident #396, the facility staff failed to communicate to staff responsible for his care of Resident #396's choice to receive resuscitative measures in the event of an emergency. On [DATE], Resident #396's clinical record was reviewed. Resident #396 was admitted on [DATE]. A review of Resident #396's admission note dated [DATE] revealed, in part: Cognitive state on arrival: cognitively intact, oriented to person, oriented to place, oriented to time, oriented to situation, able to make needs known. A review of a physician's note dated [DATE] revealed, in part: [Resident #396 is] alert, pleasant, and cooperative. A review of the physician's orders revealed that there were no orders addressing Resident #396's code status. Also, there was no code…

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, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure an accurate MDS (minimum data set)/RAI (resident assessment instrument) was completed for two residents (Residents #142 and #152) in a survey sample of 55 residents. The findings included: 1. For Resident # 142, the facility staff failed to complete Section C: Cognitive Patterns in a Quarterly assessment dated [DATE]. Resident #142's clinical record review revealed the most recent MDS assessment was a Quarterly Assessment with an ARD (assessment reference date) of 9/20/2022. Review of Section C for Cognitive Patterns revealed Section C0100, which asked if a Brief Interview for Mental Status (Section C0200-C0500) be conducted. The facility staff answered yes. Further review of the MDS revealed dashes in several sections in Section C for Cognitive Patterns.: Sections C0200-C0500 were documented as not assessed. The next section C0600- Should staff…

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, facility record review and facility documentation, the facility staff failed to ensure Preadmission Screening and Resident Review (PASARR) was completed prior to admission to the facility for one Resident (#53) in a survey sample of 55 Residents. The findings included: For Resident #53 the facility staff failed to have the PASARR prior to or since admission on [DATE] for a Resident with known history mental illness. Resident #53 was admitted to the facility with diagnoses of but not limited to seizure disorder, bipolar disorder, anxiety disorder, depression, psychotic disorder and schizophrenia. On 10/26/22 a request was made to Employee E (Social Services Director) for the PASARR for Resident #53. The Social Worker stated she could not locate the PASARR. She stated a PASARR had not been completed prior to admission, and has not been done since admission. Employee E was asked when the PASSAR was supposed to be completed and she stated that it should be done prior to admission. When asked the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to follow the nursing standard of practice for two Residents (Resident #21 and 117) in a survey sample of 55 Residents. The findings included: 1. For Resident #21, the facility staff failed to notify the physician when insulin was not available for administration. The facility staff administered blood pressure medication when the blood pressure was outside of parameters to hold the medicine on eight occasions in October, 2022. On 10/25/22 and 10/26/22, Resident #21 was visited in her room. Resident #21 was asked about her medications and was disorganized in her responses. A review of Resident #21's clinical record revealed, in part, the following: i. A physician order dated 7/27/22, that read, Humulin N 100 UNIT/ML Suspension Inject 30 unit subcutaneously two times a day related to Type 2 Diabetes Mellitus Without Complications. ii. An excerpt from…

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 interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to assist Residents who were dependent upon staff for ADL (activities of daily living) assistance, affecting 3 Residents (Residents #82, 163, and 53) in a survey sample of 55 Residents. The findings included: 1. The facility staff failed to assist Resident #82 to open the milk carton served with breakfast on 10/27/22. On 10/27/22, a clinical record review of Resident #82's electronic chart was conducted. This review revealed that on an MDS (minimum data set assessment), a significant change assessment with an ARD (assessment reference date) of 8/26/22, Resident #82 was coded as requiring one supervision and one person physical assistance for the task of eating. On 10/27/22 at 8:25 AM, Resident #82 was observed in her room with her breakfast. Surveyor observed that her milk carton was not open on her tray. When questioned, Resident #82 asked Surveyor C to open it for her. Resident #82 was encouraged to attempt to…

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 administer a medication per a physician's order for one of 55 residents in the survey sample, Resident #99. The findings include: For Resident # 99, the facility staff failed to administer the Antibiotic medication, Cephalexin 500 milligrams on 10/3/2022 at 8:53 p.m. and 10/4/2022 at 11:39 a.m. A review of nursing notes revealed, in part: 10/2/2022- Skin Wound Note-area on back side of scrotum. Round, pus filled area. MD aware. 10/4/2022 11:39 -Orders - Administration Note- Cephalexin Capsule 500 MG. Give 1 capsule by mouth every 6 hours for abscess to scrotum for 10 Days. Will give upon arrival from pharmacy. 10/3/2022 20:53-Orders - Administration Note- Cephalexin Capsule 500 MG. Give 1 capsule by mouth every 6 hours for abscess to scrotum for 10 Days. Awaiting from pharmacy Review of the Physician Orders revealed an order dated 10/3/2022 for Cephalexin 500 milligrams one capsule every 6 hours for abscess for 10 days. Review of the October 2022 Medication Administration…

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, clinical record review, and facility documentation review, the facility staff failed to implement interventions to prevent and treat pressure ulcers for one Resident (Resident #152) in a survey sample of 55 Residents. The findings included: For Resident #152, the facility staff failed to provide Prevalon boots to both feet of Resident #152, and failed to have the air mattress settings correct, causing the mattress to be too firm, which in turn increased the risk of skin breakdown/development of pressure sores. On 10/25/22 at approximately 1:45 PM, Resident #152 was observed in her bed. The Resident was asleep and not available for an interview. She was observed to have an air mattress and the setting was on 350 lbs., The Resident was thin. Both of her feet/heels were visible, and they were resting directly on the mattress, without any offloading to relieve pressure on her heels. On 10/25/22 at approximately 4:15 PM, Resident #152 was again observed lying in bed on her back. Her air mattress remained on the setting of 350 lbs. The Resident's…

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

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide adequate supervision to prevent accidents and hazards for one Resident (#78) in a survey sample of 55 Residents. The findings included: For Resident #78 the facility staff failed to provide adequate supervision for a Resident with dementia to prevent wandering into other Resident rooms. Resident #78 has diagnoses to include dementia, with wandering behaviors. She wears a wander guard bracelet to prevent her from leaving the premises unescorted. A review of the clinical record revealed the following progress note: 8/17/2022 9:30 PM Text: RP (responsible party) aware of event. Voiced that they are aware of Mom pursuing [name of a man] she believe he is her husband. Frequent monitoring implemented. An interview with LPN (licensed practical nurse) E was conducted on the afternoon of 10/24/22, and when asked if the patient was on frequent rounding, she stated that she was not aware of such. When asked if frequent rounding should be care planned, she stated that she…

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 administer oxygen in a manner to prevent the spread of infection for three Residents (Residents # 179, # 105 and # 28) in a survey sample of 55 Residents. The findings included: 1. For Resident # 179, the nebulizer tubing was not dated and was not stored in a plastic bag. Resident # 179 was admitted to the facility with the diagnosis of Chronic Obstructive Pulmonary Disease. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 9/16/2022. The MDS coded Resident #179 as requiring oxygen therapy. Review of the clinical record was conducted on 10/25/2022 - 10/27/2022. During the initial tour on 10/25/2022 at 12:50 PM, a red Oxygen in Use sign was posted on the outside of Resident # 179's bedroom door. Resident # 179 was sitting on the side of the bed. The resident's nebulizer tubing was on the nightstand. There was no date on the nebulizer tubing and it was not in a plastic bag. The nasal cannula oxygen…

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 facility documentation review, the facility staff failed to use the services of a registered nurse for one day (01/08/2022) out of the 6 days reviewed. The findings included: On 10/27/2022, the facility staff provided the nursing time punches for 01/07/2022-1/09/2022 and 02/05/2022-02/07/2022. Of the 6 days reviewed, there was no evidence of Registered Nurse (RN) coverage for one day (01/08/2022). On 10/27/2022, the facility's assessment dated [DATE] was reviewed. The staff needed in a 24-hour period for RNs, LPNs, and CNAs was determined to be 4 RN', 11-15 LPNs, and 22-46 CNAs. On 10/27/2022 at approximately 4:15 P.M., the administrator was notified there was no evidence of RN coverage on 01/08/2022. On 10/28/2022 at approximately 9:50 A.M., Employee P, the scheduler, was interviewed. When asked about the process for staffing, the scheduler stated that the process included ensuring there was one RN in the building for at least one shift in a 24-hour period. When asked about RN…

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 staff failed for one resident (Resident # 21) of 55 residents in the survey sample to ensure medications were available for administration. The findings include: For Resident #21, the facility staff failed to administer insulin as ordered by the physician because it was not available for administration. On 10/25/22 and 10/26/22, a clinical record review of Resident #21's chart was conducted. This review revealed the following: i. A physician order dated 7/27/22, that read, Humulin N 100 UNIT/ML Suspension Inject 30 unit subcutaneously two times a day related to Type 2 Diabetes Mellitus Without Complications. ii. An excerpt from the care plan for Resident #21 read, Endocrine system related to Insulin Dependent Diabetes and dx of Hypothyroidism created on: 10/20/2020 .Administer medications per physician orders. iii. The MAR (medication administration record) revealed that on 10/7/22, the 5PM dose of Humulin insulin was not administered and had a code 5 entered, which according to the legend indicated 5=Hold/See Nurse…

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 and staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure one Resident (Resident #38) was free of significant medication errors, in a survey sample of 55 Residents. The findings included: For Resident #38, the facility staff failed to administer an antibiotic as ordered by the physician to treat pneumonia on 10/22/22. On 10/25/22, during an interview with the Resident, Resident #38 reported that frequently in the evenings he doesn't receive his medications. On 10/25/22 and 10/26/22, a clinical record review was conducted. This review revealed the following: i. A physician order dated 10/18/22, read, Levaquin Tablet 500 MG (Levofloxacin) Give 1 tablet by mouth one time a day for Pneumonia for 7 Days. ii. The care plan contained a focus area that read, Infection of respiratory tract pneumonia. A related intervention read, Administer medication per physician orders. iii. Review of the Medication Administration Record (MAR) revealed that on 10/22/22, there was no indication that the Resident was 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.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pneumococcal immunizations for 2 residents in a survey sample of 5 residents reviewed for pneumococcal vaccination. The findings included: The facility staff failed to provide pneumococcal immunizations for Residents #54 and #176. On 10/27/22, clinical record review was performed for both Resident #54, admission date 8/10/22, and Resident #176, admission date 8/31/22. This review revealed no documentation with regard to pneumococcal immunization, including the resident's current pneumococcal vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication for either resident. An active physician's order was found in the clinical record for both Resident #54 and Resident #176 that read, May have Pneumovax with consent. A staff interview was conducted with the facility's Infection Preventionist who confirmed the findings and stated, We are supposed to assess whether or not a 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 staff interview, facility documentation review, clinical record review, hospital record review, and in the course of a complaint investigation, the facility staff failed to implement their abuse/neglect policies for 1 Resident (Resident #210) in a survey sample of 59 residents. The facility failed to verify if disciplinary action in effect against professional license before hire for 6 of 25 employees and failed to provide training/orientation programs that include topics such as abuse prevention for 6 of 7 employees. 1. For Resident #210, the facility staff failed to report an allegation of neglect. The allegation of neglect was bought to the attention of the facility staff by a family member of the Resident, who filed a grievance with them on 11-22-18. It was never reported to the State Agency, and the investigation was not timely, taking at least 12 days. 2a. The facility failed to verify if disciplinary action in effect against professional license before hire for six employees. 2b. CNA B, CNA 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, facility documentation review, and clinical record review, the facility staff failed to follow professional standards of practice for medication and treatment administration for 4 Residents (Residents #49, #115, #510, and #211) in a survey sample of 59 Residents. 1. For Resident #49, the facility staff failed to ensure medications were documented as having been administered. 2. For Resident # 115, the facility staff failed to remain with the resident during administration of nebulizer treatments. 3. For Resident #510, the facility staff failed to obtain an Arterial Brachial Index (ABI), and to clarify the frequency of dosing for prednisone medication, which were ordered by a physician. 4. For Resident #211, the facility staff failed to obtain a physician's order for treatment of a skin tear. The findings included; 1. Resident #49 was initially admitted to the facility 5-8-18, and readmitted after a hospitalization on 2-1-19. Diagnoses included; anxiety, diabetes,…

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 failed to ensure staff have the appropriate competencies and skills sets for 6 of 7 employees, (CNA's B, I, K, M, N AND P). CNA B, CNA I, CNA K, CNA M, CNA N, and CNA P were found to have abuse training and other training on dates that they didn't work or were coded as having more inservice hours than they actually worked on the day of the inservice. The findings include: Employee CNA I whose hire date is 2/20/18, was recorded on individual employee education record as attending 7 hours of orientation training on 2/21/18. Review of payroll records indicate CNA I worked 5.75 orientation hours on 2/21. There was no other non-computer based documented training for CNA I for the remainder of the 2018 calendar year other than on 2/20/18-2/21/18. CNA B whose hire date was 12/18/18, was recorded on the individual employee education record as attending 8 hours of education/orientation training on 12/18/18. Review of facility payroll records indicate CNA B had no hours for the date of 12/18/18. For CNA K the facility failed to…

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, staff interview, and clinical record review, the facility staff failed to maintain respect and dignity for two residents (Resident #87, Resident #29) in a sample size of 59 residents. The findings include: 1. For Resident #87, the facility staff failed to protect Resident #87's private space. A facility vendor was observed entering the room without knocking on the door. Resident #87, a [AGE] year old female was admitted to the facility on [DATE]. Diagnoses include but not limited to cerebral palsy, Parkinson's disease, dysphagia, schizoaffective disorder, bipolar, quadriplegia, and gastroesophageal reflux. Resident # 87's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/2019 was coded as a quarterly assessment. Resident # 87 was coded with a Brief Interview of Mental Status (BIMS) score of 5 out of possible 15 indicating severe cognitive impairment. Functional status for eating, dressing, and personal hygiene was coded as extensive dependence on staff. 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, resident interview, staff interview and clinical record review the facility staff failed for 1 resident (Resident #115) of 59 residents in the survey sample to ensure the resident had been assessed to self administer medications. 1) For Resident # 115, the facility staff failed to remain with the resident during administration of nebulizer treatment and failed to assess the resident to determine if self administration of medication was clinically appropriate and safe. 2) For Resident #510, the facility staff failed to provide supervision and oversight of medication administration during a nebulizer treatment and failed to assess the resident to determine if self administration of medication was clinically appropriate and safe. 3. For Resident #76 the facility staff failed to provide supervision and oversight of topical medication and failed to assess the resident to determine if self administration of medication is clinically appropriate and safe. The findings included: Resident #115, 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, resident and staff interview, facility documentation and clinical record review, the facility failed to, for one resident (Resident #78), in a survey sample of 59 residents, to allow the resident to choose his own preferred activities. Resident #78 stated the facility would not let him go outside in his wheel chair. The findings included: Resident #78, was admitted to the facility on [DATE] and was readmitted on [DATE]. Diagnoses included; stroke, anxiety, history of small bowel obstruction and hypothyroidism. Resident #78's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-8-19 was coded as a significant change in status assessment. Resident #78 was coded as having no memory deficits, did not refuse care, and was able to make own daily life decisions. The Resident was also coded as needing extensive assistance of one to staff members to perform his activities of daily living, except for independent locomotion, both on and off the units. On 2/20/19 at 1:23 PM…

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 staff failed to report to the state agency allegations of abuse or neglect for two residents (Resident #72, #210) in a sample size of 59 residents. 1. For Resident #72, the facility staff failed to report resident-to-resident altercation to the state agency. 2. For Resident #210, the facility staff failed to report an allegation of neglect. The allegation of neglect was bought to the attention of the facility staff by a family member of the Resident, who filed a grievance with them on 11-22-18. It was never reported to the State Agency, and the investigation was not timely, taking at least 12 days. The findings include: 1. For Resident #72, the facility staff failed to report resident-to-resident altercation to the state agency. Resident #72, a [AGE] year old female, had an initial admission date of 03/01/2017. Diagnoses included but not limited to cerebrovascular disease, cerebral infarction, hemiplegia, depression,…

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 complete an accurate MDS (minimum data set) RAI (Resident Assessment Instrument) for one Resident (Resident #210) in a survey sample of 59 Residents. For Resident #210, the facility staff failed to accurately code her falls prior to admission in Section J-B, and weight loss in Section K-0300. The findings included: Resident #210 was admitted to the hospital after a fall at home. Hospital admission occurred on 11-16-18, and she was discharged to the nursing facility on 11-19-18. Resident #210 stayed in the facility until 11-26-18, and was discharged back to the hospital on [DATE]. Diagnoses for Resident #210 at the time of hospitalization on 11-16-18 included, bruising of the thorax from one fall in the last 3 months at home, urinary tract infection, spinal stenosis and cervical degenerative disk disease, high cholesterol, hypertension, arthritis, history of kidney stones, and depression. Review of the nursing and physician progress…

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 and in the course of a complaint investigation the facility failed ensure they had (Pre admission Screening And Resident Review) PASARR screening prior to admission for 2 Residents (#69 & #212) in a survey sample of 59 Residents. 1. For Resident #212 the facility failed to ensure Resident had PASARR Screening prior to admission. 2. For Resident #69 the facility failed to ensure the Resident had PASARR Screening prior to admission. The findings include: 1. For Resident #212 the facility failed to ensure Resident had PASARR Screening prior to admission. Resident #212 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to( End Stage Renal Disease) ESRD requiring Hemodialysis three (3) days a week, (Resident had Hemodialysis Port in Upper Right Chest) heart failure unspecified, Type 2 Diabetes, anxiety, major depressive disorder, Depression, Psychosis, Dementia and Anemia. Resident #212's most recent…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation the facility failed to review and revise care plans for 2 Residents (#212 and #69) in a sample size of 59 residents. 1. For Resident # 212 the facility failed to develop and implement a care plan that addressed the behaviors of pulling at dialysis port and uncapping dialysis ports. 2. For Resident #69 the facility did not update care plan to add Resident is on thickened liquids and only family may give water / thin liquids. The finding include: 1. For Resident # 212 the facility failed to develop and implement a care plan that addressed the behaviors of pulling at dialysis port and uncapping dialysis ports. Resident #212 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to (End Stage Renal Disease) ESRD requiring Hemodialysis three (3) days a week, (Resident had Hemodialysis Port in Upper Right Chest) heart failure unspecified, Type 2 Diabetes, anxiety, major depressive disorder,…

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 and clinical record review, the facility staff failed to, for one resident (Resident 143) in a survey sample of 59 residents, to ensure wound care was provided in a manner to prevent infection. The wound care nurse did not clean her hands between moving from the sacrum to the heel. The findings included: Resident #143, was admitted to the facility on [DATE] and was readmitted from the hospital on [DATE]. Diagnoses included: dementia, weight loss, anemia, diabetes and high blood pressure. Resident #143's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12-6-18 was coded as a significant change in status assessment. Resident #143 was coded as having severe memory deficits, and was unable to make own daily life decisions. The Resident was also coded as needing extensive to total assistance of one to staff members to perform activities of daily living, such as bed mobility and eating. On 2/21/19 at 10:41 AM Wound care…

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, staff interviews, clinical record review, and facility documentation, the facility staff failed to provide services to provide a left hand roll as ordered by physician to prevent reduction in range of motion for one resident (Resident #29) in a sample size of 59 residents. The findings include: Resident #29, an [AGE] year old female was admitted to the facility on [DATE]. Diagnoses include but not limited to cerebrovascular disease, Alzheimer's disease, aphasia, contracture left hand, and diabetes. Resident # 29's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/2018 was coded as an annual assessment. Resident # 29 was not coded with a Brief Interview of Mental Status (BIMS) score but cognitive skills for daily decision-making were coded as severely impaired. Functional status for dressing and toileting were coded as requiring extensive assistance from staff. Functional status for eating and personal hygiene were coded as total dependence on staff. 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 Resident interview, staff interview, clinical record review and facility documentation the facility failed ensure adequate pain management for 1 Resident (Resident # 151) in a survey sample of 59 Residents. For Resident #151, the facility failed to address the pain she was experiencing in her mouth and face, in spite of her complaining to facility staff and her Psychiatric Nurse Practitioner (NP). The findings include: Resident #151 a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Asthenia (Muscle Weakness), Hypertension, Anemia, Dysphagia, Hypothyroidism, Trigeminal Neuralgia, and Dementia. The most recent (Minimum Data Set) MDS was a quarterly dated 2/1/19 and coded the Resident as having a (Brief Interview of Mental Status) BIMS score of 6 indicating severe cognitive impairment. On 2/20/19 at 12:30 PM, during initial tour of the building an interview was conducted with Resident #151. Resident #151 stated, My teeth hurt and whatever they are giving me…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure medications were available for administration for one Resident (Resident # 131) in a survey sample of 59 residents. Resident #131 was readmitted to the facility from the hospital on 1/22/2019 for treatment of Infection of PEG (Percutaneous Endoscopic Gastrostomy) tube and Urosepsis. The potassium reducing medication, Kayexalate, was unavailable from the pharmacy on 2/22/2019. Another potassium reducing medication, Veltassa, was ordered. Veltassa was not available until 2/25/2019 until 3:30 PM. The findings included: Resident #131, an [AGE] year old, was admitted to the facility on [DATE] an readmitted on [DATE]. Diagnoses included but were not limited to: Urosepsis, Infection of PEG (Percutaneous Endoscopic Gastrostomy) tube, Fluid Retention, Hypertension, Diastolic Heart Failure, Diabetes, Chronic Renal Failure, Anemia, and Lymphocytosis. Resident # 131'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 observation, resident interview, staff interview, facility documentation and clinical record review the facility failed to ensure Residents were free from unnecessary psychotropic medications for 3 Residents (#120, #25 and # 212) in a survey sample of 59 Residents. 1. Resident #120's antipsychotic medication (Risperdal) had no GDR (gradual dose reduction), excessive doses; Resident #120 had a diagnosis of dementia (no psychotic disorders). 2. Resident #25 has been on the same dosage of Zyprexa (antipsychotic) since 11-22-17 for mood disorder. She has a diagnosis of dementia with no behaviors warranting the use of an antipsychotic. 3. For Resident # 212 the facility failed to ensure Resident had proper diagnosis for administration of Zyprexa (anti-psychotic medication) and no gradual dose reduction attempted. The findings included: 1. Resident #120's antipsychotic medication (Risperdal) had no GDR (gradual dose reduction), excessive doses; Resident #120 had a diagnosis of dementia (no psychotic…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility documentation review and clinical record review the facility staff failed to ensure residents are free of significant medication errors for 2 of 59 residents. 1. For resident # 510 the facility failed to provide insulin as per physician's orders on 4 occasions. 2. For Resident # 131, the facility staff failed to obtain medication prescribed to treat too much potassium in the body. The findings include: 1. Resident #510, a [AGE] year old male, was admitted to the facility on [DATE]. His diagnosis included but are not limited to: chronic pulmonary edema, Muscle weakness, Difficulty in walking, other symptoms and signs involving the musculoskeletal system, cognitive communication deficit, heart failure, type 2 diabetes, sepsis, morbid obesity, hypertension, atherosclerotic heart disease, acute respiratory failure with hypoxia, disorder of kidney and ureter, and shortness of breath. Resident #510 did not have a complete MDS (minimum data set) (an assessment tool) due to being a new admission.…

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. LPN A failed to lock and secure her assigned medication cart during the course of medication administration. On 04/10/2019 at approximately 11:05 AM, while performing the Medication Administration Task, LPN A was observed leaving her medication cart unlocked and unsecured in the common hallway on Unit 1, between rooms [ROOM NUMBERS], and entered room [ROOM NUMBER] to administer medications to Resident #103. When asked how the medication cart should be left while administering meds, she replied It should be locked when I am away from it. On 04/10/2019 at approximately 11:40 AM, the Unit Manager (RN A) verified that LPN A was the only staff member assigned to medication administration for the current shift on Unit 1 and was responsible for 2 out of 2 medication carts located on Unit 1. On 04/10/2019 at approximately 11:45 AM, an unattended medication cart located outside of room [ROOM NUMBER] on Unit 1 was observed to be unlocked and unsecured. At 11:50, LPN A was observed exiting from room [ROOM NUMBER]. She…

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 the facility failed to provide dental care to 1 Resident (Resident # 151) in a survey sample of 59 Residents. The findings include: Resident #151 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Asthenia (Muscle Weakness), Hypertension, Anemia, Dysphagia, Hypothyroidism, Trigeminal Neuralgia, and Dementia. Her most recent (Minimum Data Set) MDS was a quarterly dated 2/1/19 coded Resident as having a (Brief Interview of Mental Status) BIMS score of 6 indicating severe cognitive impairment. On 2/20/19 at 12:30 PM during initial tour of the building an interview was conducted with Resident #151 and she stated My teeth hurt and whatever they are giving me don't help. When asked if she had been to the dentist she stated No I haven't been to a dentist in years and that's just what I need to do. On 1/20/19 Interview with Other Employee A who stated Yes I see [Resident 151] and 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 observation, staff interview, and facility documentation review, the facility staff failed to administer medications in a manner to prevent the spread of infection for 1 resident (Resident #103) in a sample size of 11 residents. For Resident #103, LPN A failed to wash her hands prior to putting on non-sterile gloves in preparation for the administration of his eye drops. The Findings included: Resident #103, an [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to previous stroke, atrial fibrillation (abnormal heart rhythm), dementia, cataracts, and depression. Resident #103's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/2019 was coded as a Quarterly Assessment. Resident #103 was coded with a Brief Interview of Mental Status (BIMS) score of 9 out of possible 15 indicating moderately impaired cognition. On 04/10/2019 at approximately 11:30 AM, LPN A was observed preparing to administer eye drops to Resident #103.…

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 and clinical record review, the facility failed for one resident (Resident #40) in a survey sample of 59 residents, to maintain equipment in a safe operating condition. Resident #40's wheel chair pedals were padded with towels and duct tape. The findings included: On 2/21/19 at 4:06 PM Resident #40's wheelchair pedals were observed to be padded with towels and duct tape. On 2/22/19 at 12:57 PM Resident #40's wheelchair were observed to have towels and duct tape to pad the w/c pedals. On 2/25/19 at 11:00 AM, the resident was observed in bed and the wheelchair had new cushions on the pedals. Resident #40 stated, I like it. On 2/25/19 at 3:10 PM, the Administrator, DON (director of nursing) and the corporate nurse were present, informed of above findings.

Based on observation, staff interview and facility document review, the facility staff failed to prepare and distribute food in a sanitary manner from the main kitchen. Ten large baking pans, identified as ready for use, were stored nested and wet. The findings include: On 11/7/17 at 12:45 p.m. accompanied by the food services director, the kitchen was inspected. Ten large baking pans, identified by the food services director as ready for use, were stored on a rack nested and wet. As the pans were separated, moisture was observed and felt on the baking surfaces of the pans. The food services director was interviewed at the time of this observation about the wet pans. The food services director stated the pans were not supposed to be stacked and stored wet. The food services director stated all pans were washed and sanitized in the three compartment sink and were supposed to dry on the designated drying rack prior to stacking/storing. The facility's dietary services policy titled Sanitization (revised December 2008) stated, The food service area shall be maintained in a clean and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed, for 1 resident (Resident #13) in the survey sample of 24 residents, to ensure that Resident #13 was free of a physical restraint. The facility staff failed to ensure that Resident #13 was free of being restrained by a bed sheet tied around a Geri-chair. The Findings included: Resident #13 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #13's diagnoses included Unspecified Dementia without Behavioral Disturbance, Bipolar Disorder, Insomnia, and Major Depressive Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 9/2/17, coded Resident #13 as having a Brief Interview of Mental Status Score of 3, indicating severely impaired cognition. On 11/7/17 at 2:45 P.M. an unannounced tour was conducted of the facility. Resident #13 was lying quietly in her bed. Resident #13 was on 1:1 supervision provided by a Wing-Helper (Employee A). When…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to follow the professional standards of practice for documentation of medication administration for 1 resident (Resident #8) in the survey sample of 24 residents. For Resident #8, the facility staff failed to document the administration of a dietary supplement on two occasions in August, 2017. The Findings included: Resident #8 was a [AGE] year old who was admitted to the facility on [DATE]. Resident # 8's diagnoses included Generalized Muscle Weakness, Gastroesophageal Reflux Disease, and Severe Protein Calorie Malnutrition. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 9/20/17, coded Resident #8 as having a Brief Interview of Mental Status Score of 5, indicating severely impaired cognition. On 11/8/17 a review was conducted of Resident #8's clinical record, revealing the following signed physician's order: 8/1/17. Mighty Shake by mouth three times 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 staff interview, facility documentation review, and clinical record review, the facility staff failed to provide the highest practicable well-being for Resident #7. The facility staff failed to assure that physician ordered blood glucose testing was performed and documented, and insulin given, if necessary, for Resident #7. Findings included: Resident #7, a [AGE] year-old female, was admitted to the facility on [DATE]. Resident #7's diagnoses included neurogenic bladder, atrial fibrillation, cerebral vascular accident (stroke), hemiplegia/hemiparesis, dysphagia, high cholesterol, coronary artery disease, anemia, hypertension, and diabetes. Resident #7's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/28/2017 was coded as a quarterly assessment. Resident #7 was coded a BIMS (Brief Interview of Mental Status) score of 5/15, indicating severe cognitive deficiency. Resident #7 was also coded as requiring total dependence of 2+ persons for her activities of daily living, and…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure tubing for a urinary catheter was anchored for one of 24 residents in the survey sample. The tubing for Resident #4's urinary catheter was not anchored to minimize tension on the tubing as required in her plan of care. The findings include: Resident #4 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, sacral pressure ulcer, COPD (chronic obstructive pulmonary disease), peripheral vascular disease, stroke and anemia. The minimum data set (MDS) dated [DATE] assessed Resident #4 as cognitively intact. On 11/8/17 at 9:10 a.m., accompanied by registered nurse (RN) C and RN (D) responsible for wound care, the position of Resident #4's urinary catheter tubing was observed during a dressing change to the resident's sacral pressure ulcer. The catheter tubing was not anchored in any manner to the resident's upper leg and/or thigh area to minimize tension…

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, Family and Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, facility staff failed to employ sufficient support staff to provide timely serving of meals and feeding assistance for 1 resident (Resident #9) in the survey sample of 24 residents. Facility staff failed to provide delivery of the Lunch meal tray and feeding assistance in a timely manner for Resident #9. The Findings included: Resident #9 was admitted to the facility on [DATE]. Resident #9's diagnoses included: Malignant neuro-endocrine tumors, hypertension, diabetes, high cholesterol, dementia, Muscle Weakness, anemia, and arthritis. The Minimum Data Set, was a full admission Assessment, with an Assessment Reference Date (ARD) of 10-27-17, coded Resident #9 as usually being understood and usually able to understand. In addition, Resident #9 was coded as requiring extensive assistance of one staff member for all activities of daily living…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to ensure biologicals and medications were stored appropriately on three of three units. 1. On The [NAME] Unit , one PPD (purified protein derivative) dated as opened [DATE] was available for administration to Residents. A second vial was opened with no date when opened. PPD is only good for 30 days after opened and accessed; 2. On the [NAME] Unit, a vial of flu vaccine was opened without a date. 3. On the [NAME] unit, two vials of flu vaccine was open without a date. The findings included: 1. On The [NAME] Unit , one PPD (purified protein derivative) dated as opened [DATE] was available for administration to Residents. A second vial was opened with no date when opened. PPD is only good for 30 days after opened and accessed. On [DATE] at 12:55 PM, during the initial tour, a vial of opened PPD was dated as having been opened on [DATE], over 30 days old. PPD is a solution that is utilized to test Residents and staff…

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.