Courtland Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, clinical record review and facility documentation, the facility staff failed allow the residents' involvement in the care plan conference for 1 resident (Resident #67) in the survey sample of 51 residents.The findings Include:The facility staff failed to allow the residents' involvement in the care plan conference on 1/21/26.Resident #67 was initially admitted to the facility on [DATE], after an acute care hospital stay. The residents' diagnoses included dementia, colitis, and high blood pressure. The quarterly MDS assessment, with an assessment reference date (ARD) of 1/15/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 11 out of a possible 15. This indicated that Resident #67's cognitive abilities for daily decision making were moderately impaired. An interview was conducted with Resident #67 on 1/22/26 at 3:14 PM. Resident #67 stated that she did not like the activities the facility offered and wanted to move to a town closer…

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, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to one dependent Resident (Resident #10) in a survey sample of 51 Residents.The findings include: Resident #10 was originally admitted to the facility 9/19/2015 and re-admitted from an acute care facility on 7/11/25. The current diagnoses included; Pressure Ulcer Right Hip, Stage 4, Pressure Ulcer other site Stage 4 and Acquired absence of the Right Knee, above.The quarterly review Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #10 cognitive abilities for daily decision making were intact. In Section GG Functional Abilities coded resident as dependent with showers/bathe self, toileting and personal hygiene. Resident coded as independent with eating.The person-centered care plan dated 4/25/25 read that the resident has an…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family interview, staff interview, clinical record review and review of facility documentation the facility staff failed to ensure the necessary treatment, care and services were initiated for a Stage 2 pressure ulcer for 1 of 51 residents (Resident #96), a closed record resident, in the survey sample.The findings include: Resident #96 was originally admitted to the facility 06/09/23 and discharged to an acute care facility on 6/28/23. The current diagnoses included; Quadriplegia and Pressure induced deep tissue damage of the sacrum. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/16/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #96 cognitive abilities for daily decision making were intact.In sectionGG(Functional Abilities) the resident was coded as dependent toileting hygiene, lower body dressing, putting on/taking off footwear. Requires substantial/maximal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for 1 of 51 residents (Resident #11), in the survey sample.The findings include:Resident #11 was originally admitted to the facility 5/23/24 and readmitted on [DATE] The current diagnoses included end stage renal disease requiring dialysis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/23/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #11 cognitive abilities for daily decision making were intact. The person-centered care plan dated 7/28/25 read that Resident #11 receive hemodialysis Monday, Wednesday and Friday (M/W/F) related to End Stage Renal Disease (ESRD). The Goal for the resident is resident will have immediate intervention should any s/s of complications from dialysis occur…

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 and staff interviews and a review of clinical records, the facility staff failed to document the results of in-house COVID and influenza tests for 1 of the 51 residents in the survey sample (Resident #37). The findings included:Resident #37 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses include diabetes, atrial fibrillation, and renal insufficiency. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/21/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 10 out of a possible 15. This indicated Resident #37's cognitive abilities for daily decision making were moderately impaired. In section GG0130. Self-Care: the resident was coded as requiring setup or clean-up assistance with eating; partial/moderate assistance with oral hygiene and upper-body dressing; dependent assistance with toileting; lower-body dressing; putting on/taking off…

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

Based on observations and staff interviews the facility staff failed to follow infection control practices. Therefore, increasing the chances of spreading infections, illnesses and diseases for 1 of 51 residents, Resident #10 in the survey sample. The findings include: Resident #10 was originally admitted to the facility 9/19/2015 and re-admitted from an acute care facility on 7/11/25. The current diagnoses included; Pressure Ulcer Right Hip, Stage 4, Pressure Ulcer other site Stage 4 and Acquired absence of the Right Knee, above. The quarterly review Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #10 cognitive abilities for daily decision making were intact. In Section M skin conditions coded resident as dependent with showers/bathe self, toileting and personal hygiene. Resident coded as independent with eating.The person-centered care plan dated revised on 1/05/26 read resident has an actual impairment…

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

Based on staff interviews and a review of Infection Control documentation, the facility failed to maintain records of staff COVID-19 vaccinations. The findings included:On 1/28/26 at approximately 3:54 PM, the Infection Control task was completed with an interview with the Infection Preventionist (IP). The IP stated that education on COVID-19 vaccines is provided only to residents and/or their representatives. The IP also stated that there are no records of staff vaccinations because it is no longer a question asked of current or prospective hires. She stated she was recently employed by the facility and had not received the COVID-19 vaccine. The IP further stated that facility staff were not provided with education on the benefits and potential risks of the COVID-19 vaccine, nor were they offered the vaccine or information on how to obtain it. The facility's protocol, revised 7/25/23, titled Guidance and Protocol- COVID-19, stated under COVID-19 Vaccination that staff may be employed without providing evidence of COVID-19 vaccination. Vendors and contractors may provide services…

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 information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The findings included: A review of RN staffing for April 3, 2021 through March 13, 2022 the facility staff was unable to provide evidence that an RN provided services in the facility for at least 8 consecutive hours on 5/15/21, 5/29/21, 5/30/21, 6/27/21, 7/17/21, 7/24/21, 10/2/21, 11/27/21, 12/25/21, 1/9/22, 1/15/22, 1/16/22, 3/5/22, 3/6/22, 3/12/22 and 3/13/22. An interview was conducted with the Staffing Coordinator on 3/14/22 at approximately 4:05 p.m. The Staffing Coordinator stated she was new to the position but based on the formula for staffing she not instructed to staff a RN for at least 8 consecutive hours each day. The Staffing Coordinator stated there are few RNs other than the Director of Nursing, the Assistant Director of Nursing and maybe the MDS Coordinator who work in the facility at least 8 consecutive hours each day. On 3/17/22 at approximately 5:45…

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 during the tray line service, resident interview, staff interviews, and clinical record review, the facility staff failed to serve proper meat portions and mashed potatoes per recipe to provide person-centered determined nutritional needs based on the Registered Dietitian's assessment for 71 of 83 residents in the facility. The findings included: On 3/1/22 at approximately 12:05 p.m., an observation of the midday meal service was observed. The general meal served was 3 ounces (oz.) of ham, 1 twist of an orange, 1 ounce of pineapple sauce, herb roasted red potatoes, mashed potatoes for mechanically altered diets, garden blended vegetables, corn bread, and peach crisp. The alternate was cube steak with brown gravy, and spiral noodles. During the tray line observation on 3/1/22 at approximately 12:05 p.m., the [NAME] was asked to weigh the portion of ham slices served. The ham slice weighed between 1 oz and 1.5 oz. The [NAME] stated she cut the ham slices at over 3 ounces to account for loss of water during cooking but it never occurred the portion sizes would…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. The facility staff failed to notify Resident #87's responsible party timely of an acute change of condition that required the resident to be transferred to the hospital on 2/3/22 via 911. Resident #87 was admitted to the facility on [DATE] with diagnoses to include but not limited to Chronic Kidney Disease, Stage 5. Diabetes Mellitus, Anemia, Obesity, and Atrial Fibrillation. Resident #87 was discharged to the hospital on 2/3/22. The most recent comprehensive Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 1/27/22. The Brief Interview for Mental Status for Resident #87 was coded as a 15 out of a possible 15, indicating the resident was cognitively intact and capable of daily decision making. Under Section F0400 Interview for Daily Preferences Resident #87 was coded as a 1-Very Important for: How important is it to you to have your family involved in discussions about your care? Under Section M Skin Conditions Resident #87 was coded for being at risk for developing…

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

Based on employee record review, facility document review and staff interviews the facility staff failed to implement their Abuse/Neglect Prevention Policy for screening of new employees. Criminal Background Checks were not obtained for 12 current employees within 30 days of their hire date, Sworn Statements were not obtained for 16 current employees upon hire, and a Nursing License was not obtained for 2 current employees upon hire. The findings included: On 3/14/22 twenty-five current employee records were reviewed. The employee record review revealed that 12 current employees did not have a Criminal Background Checks. There were also 16 current employees that had no Sworn Statements upon hire. The employee record review also revealed that Nursing Licenses for 2 current employees were not obtained. On 10/14/22 at 10:30 a.m., an interview was conducted with the Business Office Manager (BOM) regarding the current employees with missing criminal background checks, sworn statements and nursing licenses. The BOM stated, I have only been here since the end of December and have not been…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a family interview, staff interviews, and review of facility documents, the facility staff failed to have on duty sufficient nursing staff with the appropriate skills sets to provide nursing services during the 3:00 p.m. - 11:00 p.m., shift on 11/19/21. The findings included: Resident #83 was originally admitted to the facility 11/19/21, was discharged to acute care 11/26/21. The resident's diagnoses included status post decompression and fusion of the lumbar spine and polymyalgia rheumatic. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/26/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #83's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with transfers, extensive assistance of one person with dressing 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.

Based on record review and staff interview the facility staff failed to ensure Agency Staff completed appropriate competencies and skill sets to provide nursing related services to meet resident needs. The findings included: A review of the facility's as work staffing schedule for the prior two weeks (February 20 through March 5th 2022) of the unannounced Medicaid/Medicare survey which started (March 09, 2022) indicated: 86 % of the direct care nursing staff were as needed agency staff. The facility utilized two separate agencies. During an interview on 03/17/2022 at 10:45 A.M. with the Corporate [NAME] President of Operations, she stated, the facility was operating on 14% company licensed nursing staff with the remaining staff from the two agencies. During an interview on 03/17/2022 at 10: 47 A.M. with the administrator she stated, the facility had a contracted agreement with two agencies for staffing. Agency staff agreement #1 was signed and dated (11/18/21). Agency staff agreement #2 was signed and dated 10/26/21. The facility was noted to have two (2) signed and dated contracted…

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 interviews, clinical record review and facility documentation, the facility staff failed to administer a significant medication for 1 out of 44 residents (Resident #47) in the survey sample. The findings included: 1. The facility staff failed to administer 12 doses of the significant medication (Zyvox) as ordered by the physician to treat a Urinary tract infection (UTI) for Resident #47. Resident #47's Minimum Data Set (MDS - an assessment protocol) a PPS 5-day assessment with an Assessment Reference Date of 02/14/22 coded Resident #47's Brief Interview for Mental Status (BIMS) scored a 06 out of a possible score of 15 indicating severe cognitive impairment. Resident #47's Minimum Data Set (MDS - an assessment protocol) a PPS 5-day assessment with an Assessment Reference Date of 02/14/22 coded Resident #47's Brief Interview for Mental Status (BIMS) scored a 06 out of a possible score of 15 indicating severe cognitive impairment. The MDS coded Resident #47 requiring total dependence of one with…

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

Based on staff interview, facility record review, and review of the facility's policy, the facility staff failed to consistently have the Medical Director or Designee present for 1 of 4 quarterly meetings. The findings included: An interview was conducted with the Administrator on 03/17/22 at approximately 2:10 p.m. The facility's signature sheets were reviewed for their Quality Assurance (QA) meetings held on 02/28/22, 11/05/21, 07/12/21 and 03/10/21, which revealed the Medical Director or his designee were not present for the quarterly QA meeting held on 02/28/22. A debriefing was held with the Administrator and [NAME] President of Operations on 03/17/22 at approximately 5:45 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program with a revision date of 02/2020. Authority: The Administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements.

Based on resident interview, staff interviews, clinical record review and facility documentation review, the facility staff failed to invite 1 of 44 residents (Resident #64) in the survey sample to participate in her Person-Centered care plan meeting. The findings included: Resident #64 was admitted to the nursing facility on 11/12/21. Diagnosis for Resident #64 included but not limited to Type II diabetes. The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 02/22/22 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. During the initial tour on 03/09/22 at approximately 3:27 p.m., an interview was conducted with Resident #64 who stated, Care plan meetings don't happen here. I was never invited nor did I receive a letter to attend a care plan meeting. An interview was conducted with the Social Worker (SW) on 03/10/22 at approximately 10:35 p.m., who stated, I invited Resident #64 to attend her care plan meeting verbally, but a care plan letter…

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 record review, staff and individual interviews the facility staff failed to provide one resident (Resident #37) in the survey sample of 44 residents with a quarterly financial statement. The findings included: Resident #37 was admitted to the facility on [DATE] with diagnoses of sequela, neuromuscular dysfunction of bladder, paraplegia, hypertension, anxiety disorder, contracture of right hip, contracture of left hip, and depression. The facility staff failed to provide Resident #37 with a quarterly financial statement. Resident #37 was noted to be his own authorized legal representative. A Quarterly Minimum Data Set (MDS) assessed Resident #37 as having a Basic Interview for Mental Status (BIMS) score of 13. In the area of Activity's of Daily Living (ADL's) this resident was assessed as requiring extensive assistance in the area of bed mobility and transfer. A Care Plan Dated: 2/11/2022 indicated: The resident needs a safe environment with: (floors free from spills and/or clutter; adequate light; 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 staff interviews, and clinical record review, the facility staff failed to complete and implement the baseline care plan within 48 hours of a resident's admission and failed to provide a written baseline care plan summary to one resident representative for 2 of 44 residents (Resident #83 and #67), in the survey sample. The findings included: 1. Resident #83 was originally admitted to the facility 11/19/21, was discharged to acute care 11/26/21. The diagnoses at the time of the resident's 11/19/21 admission included; status post decompression and fusion of the lumbar spine and polymyalgia rheumatic. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/26/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #83's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and resident interviews, the facility staff failed to revise the care plan for one resident, Resident #37, in the survey sample of 44 residents, to include interventions for this resident sharing alcohol with other residents. The findings included: Resident #37 was admitted to the facility on [DATE] with diagnoses of sequela, neuromuscular dysfunction of bladder, paraplegia, hypertension, anxiety disorder, contracture of right hip, contracture of left hip, and depression. The facility staff failed to revise Resident #37 care plan to include interventions for sharing alcohol with other residents. A Quarterly Minimum Data Set (MDS) assessed Resident #37 as having a Basic Interview for Mental Status (BIMS) score of 13. In the area of Activity's of Daily Living (ADL's) this resident was assessed as requiring extensive assistance in the area of bed mobility and transfer. A Care Plan Dated: 2/11/2022 indicated: The resident needs a safe environment with: (floors free from spills and/or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, staff interviews and facility document review the facility staff failed to ensure 1 of 44 Residents (Resident #61) was provided an assistive device to prevent accidents, Resident #61. The facility staff failed to ensure Resident #61's wanderguard device was in place to prevent elopement. The findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses to include but not limited to Alzheimer's Disease, Anxiety and Dementia. The most recent comprehensive Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 11/20/2. The Brief Interview for Mental Status for Resident #61 was coded as a 3 out of a possible 15, indicating the resident was severely cognitively impaired and incapable of daily decision making. Under Section E Behavior; E0900 Wandering-Presence and Frequency, Resident #61 was coded as a 3=Behavior of this type occurred daily. Under E1000 Wandering-Impact, Resident #61 was coded Yes=Does 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 observations, resident interview, staff interviews, and clinical record review, the facility staff failed to ensure a resident who receives oxygen therapy for COPD and CHF had oxygen flowing for 1 of 44 residents (Resident #56), in the survey sample. The findings included: Resident #56 was originally admitted to the facility 9/19/16 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; COPD, congestive heart failure (CHF), and respiratory failure with hypoxia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/15/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #56's cognitive abilities for daily decision making was intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with personal hygiene, bathing, dressing, and toileting, extensive assistance of two people with bed mobility 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.

Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to have an ongoing review of antibiotic stewardship and monitor the effectiveness of the resident's antibiotic therapy. The findings included: On 3/17/22 at approximately 2:30 PM an interview was conducted with ASM (Administrative Staff Member) #3 and via telephone with ASM #6 concerning the antibiotic Stewardship Program. ASM #3 stated, The DON (ASM #4) has the book with the line listings but he is no longer here. I only have the education book. An observation of the education book was made. There were no line listings for the months of January, February and March of 2022. ASM #6 stated the DON was working on the book but never finished it. On 3/17/22 at approximately 5:45 PM a Pre-exit interview was conducted with the Administrator, The [NAME] President of Operations and with the [NAME] President of Clinical Services. No comments were voiced at this time. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interview the facility staff failed to maintain an ongoing pest control program to ensure the facility is free of insects. The findings included: During the Resident Council meeting on 03/10/22 at 10:00 A.M. Resident #73 stated he had ants in his room. Resident #73 was admitted to the facility on [DATE] and had a Brief Interview of Mental Status (BIMS) score of 14. During an interview on 03/10/22 at 11:05 a.m with Resident #73. He stated, ants have been crawling all over the room. Observations made in Resident #73's room indicated that a 3 inch by 4 inch by one half inch deep area of the right corner of the room flooring was missing. During this observations, ants were noted to be coming in from the outside under the window and air/heating unit area. Ants were observed to be under a night stand. Ants were observed to be on the bed and covers of Resident #73 bed. Resident #73. stated, he has been fortunate that the ants had not bitten him. During an interview on 3/10/22 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide evidence that 4 of 44 residents in the survey sample, were given the opportunity to formulate an advance directive; Residents #24, #81, #73, and #37. The findings included: 1. Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to muscle weakness, difficulty walking, high blood pressure and type two diabetes mellitus. Resident #24's most recent MDS (Minimum Data Set) assessment was a quarterly MDS with an ARD (assessment reference date) of 12/27/19. Resident #24 was coded as being moderately impaired in cognitive function scoring 09 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Review of Resident #24's March 2020 POS (physician order summary) revealed that she had an order to be a DNR (Do Not Resuscitate). This order was initiated on 9/19/19. Review of Resident #24's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interviews, family interview, staff interviews, and clinical record review, the facility's staff failed to provide necessary care and services to 1 of 41 residents (Resident #132), in the survey sample to manage diabetes by obtaining blood sugars, and administering blood sugar medications. This failure resulted in more than minimal consequence for the resident, with blood sugar readings ranging 450 - 577 mg/dl, accompanied by chest pain which required an emergency room visit and 24 hour observation for stabilization at an acute care hospital. The findings included: Resident #132 was originally admitted to the facility 3/9/20, was sent to the hospital on 3/10/20 and returned on 3/11/20. The current diagnoses included but not limited to, long term use of insulin secondary to diabetes and diabetic ketoacidosis, vancomycin resistant urinary tract infection, heart disease including a heart attack. The admission nursing assessment dated [DATE], coded the resident as alert and oriented to person,…

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 facility record review and staff interviews the facility staff failed to ensure implementation of an ongoing antibiotic stewardship program. The findings included: On 03/12/20 at 03:29 P.M. the infection control program and antibiotic stewardship program was reviewed from January 2019 through February 2020 with the Staff Development Coordinator. Infection Control monitoring, tracking and trending was in place however, there was no antibiotic stewardship program in place for the months of March, April, May, and June of 2019. The Staff Development Coordinator was asked where the antibiotic use monitoring protocols were for those missing months. The Staff Development Coordinator stated, I'm not sure, I only started in December 2019 and this is all I have. On 3/12/20 at 3:45 P.M. an interview was conducted with the Nurse Consultant regarding the expectations for antibiotic stewardship for the 4 missing months. The Nurse Consultant stated, I would expect for who ever is doing the tracking and trending for our infection control program to also follow through with the antibiotic…

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 that facility staff failed to implement abuse policies and thoroughly investigate a skin injury of unknown source on two occasions for one of 44 residents in the survey sample, Resident #44. The findings include: 1. Resident #44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to unspecified dementia without behavioral disturbance and chronic obstructive pulmonary disease. Resident #44's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 1/23/20. Resident #44 was coded as being severely impaired in cognitive function scoring 04 out of possible 15 on the BIMS (Brief Interview for Mental Status Exam). Resident #44 was coded as being totally dependent on two plus persons with bed mobility and transfers; and totally dependent on one person with dressing, toileting, personal…

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 that facility staff failed to thoroughly investigate a skin injury of unknown source on two occasions for one of 44 residents in the survey sample, Resident #44. The findings include: Resident #44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to unspecified dementia without behavioral disturbance and chronic obstructive pulmonary disease. Resident #44's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 1/23/20. Resident #44 was coded as being severely impaired in cognitive function scoring 04 out of possible 15 on the BIMS (Brief Interview for Mental Status Exam). Resident #44 was coded as being totally dependent on two plus persons with bed mobility and transfers; and totally dependent on one person with dressing, toileting, personal hygiene, and bathing. Review of…

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

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 adhere to accepted standards of quality for medication administration for 1 of 44 residents in the survey sample, Resident #66. The facility staff failed to ensure medications were administered as ordered and failed to observe Resident #66 ingest the ordered medications. The findings included: Resident #66 was originally admitted to the facility on [DATE]. Diagnoses included but were not limited to, Bipolar Disorder, Depression and Parkinson's Disease. Resident #66's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 02/27/2020 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #66 as independent with personal hygiene, independent with setup help only for eating, requiring supervision of 1 for toilet use, bed mobility and transfer and total dependence of 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.

Based on clinical record review and staff interviews, the facility staff failed to ensure 1 of 44 residents (Resident #39), in the survey sample, did not receive as needed (PRN) Ativan for greater than 14 days without the physician and/or prescribing practitioner evaluating the resident for the appropriateness of continuous PRN use. The findings included: Resident #39 was originally admitted to the facility 2/25/14 and had never been discharged from the facility. The resident's diagnoses included; depression and hypertension. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/17/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #39's cognitive abilities for daily decision making were moderately impaired. The 1/17/20, MDS assessment also revealed Resident #39 exhibited mood problems (feeling tired 7-11 days and appetite changes 2-6 days over two weeks). Review of the physician's order summary revealed an order dated 2/3/20, which read *Ativan…

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.