Culpeper Health & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. For Resident #86, the facility staff failed to implement the care plan for pressure injury (1) care. The comprehensive care plan dated, 3/1/24, documented in part, Focus: Skin Impairment: The resident has a skin impairment: R/L (right/left) groin necrotizing fasciitis post-surgical, R/L ABD (abdominal) rash, L axilla hidradenitis, L/R scrotum hidradenitis, R lateral groin post-surgical necrotizing fasciitis, L groin post-surgical necrotizing fasciitis, sacrum pressure. The Interventions documented in part, Notify MD (medical doctor) as indicated. Observe area for signs of improvement or decline. Treatment as ordered. The wound care nurse practitioner note dated 5/20/24 documented in part, Sacrum scar tissue. The wound care physician notes dated, 5/31/24, documented in part, Sacrum - stage 2 (2) measuring approximately 1x1x 0.1 cm (centimeters) in size. The physician order dated 5/31/24, documented, Sacrum: Cleanse with wound cleanser, pat dry. Apply silver alginate and cover with border gauze dressing every…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide care and services to promote or maintain the highest level of well being for two of 50 residents in the survey sample; Residents #269 and #151. The findings include: 1. For Resident #269, the facility staff failed to evidence that an IV antibiotic medication that was available, was administered as ordered on six occasions, on 7/13/23 (two doses), 7/14/23 (two doses) and 7/15/23 (two doses). Resident #269 was admitted to the facility on [DATE] and discharged on 7/26/23. The resident was coded on the admission MDS dated [DATE] coded the resident as being cognitively intact in ability to make daily life decisions, scoring a 15 out of a possible 15 on the BIMS. A review of the physician's orders and the MAR (Medication Administration Record) for July 2023 revealed the following regarding a medication Teflaro (1): An order dated 7/11/23 for Teflaro IV (intravenous) 400 MG…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to prevent one of 50 residents in the survey sample, Resident #269, from a significant medication error. The findings include: 1. For Resident #269, the facility staff failed to ensure that Resident #269 was free of significant medication error on six occasions, on 7/13/23 (two doses), 7/14/23 (two doses) and 7/15/23 (two doses). Resident #269 was admitted to the facility on [DATE] and discharged on 7/26/23. The resident was coded on the admission MDS dated [DATE] coded the resident as being cognitively intact in ability to make daily life decisions, scoring a 15 out of a possible 15 on the BIMS. A review of the physician's orders and the MAR (Medication Administration Record) for July 2023 revealed the following regarding a medication Teflaro (1): On 7/10/24 at 3:00 PM, ASM #3 (Administrative Staff Member) the Regional Director of Clinical Services, provided the pharmacy delivery…

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

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain one of one kitchen in a safe and sanitary manner. The findings include: On 7/8/24 at 11:20 AM during the kitchen facility task, observations of food debris including crumbs, onion skins, lettuce and paper on floor of the kitchen. Observations of the freezer temp logs revealed there was no evidence of a second freezer temperature on 7/7/24 and no morning freezer temperature on 7/8/24. An interview on 7/8/24 at 11:30 AM with OSM (other staff member) # 3 the food services manager. When asked about the freezer temp logs, OSM #3 stated, they are to be done at the beginning and end of each shift. These were not done. We are short two staff today. When asked about the kitchen floor cleanliness, OSM #3 stated, it needs swept. When asked if it was cleaned the evening before, OSM #3 stated, it should have been, but I do not know. On 7/11/24 at 9:10 AM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional…

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, clinical record review and facility document review, it was determined the facility staff failed to implement infection control practices for four of four residents in medication administration and one of one infection control program, Residents #45, #25, #132, #118 and the facility. The findings include: 1.The facility staff failed to follow infection control practices for Resident #45. The blood glucose (BG) glucometer was not cleaned prior to or after use on Resident #45's during the medication administration observation. Resident #45 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (DM), vascular dementia and congestive heart failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/28/24, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately…

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, clinical record review and facility document review, it was determined that the facility staff failed to maintain the call bell in a position accessible to the resident for two of 50 residents in the survey sample, Resident #89 and Resident #13. The findings include: 1. For Resident #89 (R89), 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 6/18/24, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section GG coded R89 not having any impairment in the upper extremities and being dependent on staff for toileting and requiring substantial/maximal assistance for personal hygiene. The comprehensive care plan for R89 documented in part, ADLs (activities of daily living): [Name of R89] has an ADL self-care performance deficit r/t (related to) 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 Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement the baseline care plan for one of 50 residents in the survey sample, Residents #470. The findings include: The facility failed to implement a baseline care plan to monitor Resident #470's Aspira Drain. Resident #470 was admitted to the facility on [DATE] with diagnosis that included but were not limited to cancer, congestive heart failure and adult failure to thrive. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/10/24, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for bed mobility, transfer, hygiene/bathing and supervision for eating. A review of the comprehensive care plan dated 7/10/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan to reflect the residents current status for two of 50 residents in the survey sample; Resident #148 and #120. The findings include: 1. For Resident #148, the facility staff failed to review and revise the comprehensive care plan to reflect the smoking assessment that the resident required supervision for smoking. The care plan documented on 3/8/24 that the resident may smoke independently. Resident #148 was admitted to the facility on [DATE] and was coded on the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], as being cognitively intact in ability to make daily life decisions, scoring a 14 out of a possible 15 on the BIMS (Brief Interview for Mental Status exam). On 7/8/24 at 3:00 PM, Resident #148 was observed self-propelling his wheelchair down the main front sidewalk of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care for dependent residents for three of 50 residents in the survey sample, Residents #90, #89 and #151. The findings include: 1. For Resident #90 (R90), the facility staff failed to provide ADL care to assist with personal hygiene. R90 was observed having untrimmed long fingernails on the right hand. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/22/24, the resident scored 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section GG coded R90 requiring partial/moderate assistance for personal hygiene and supervision or touching assistance for bathing. On 7/8/24 at 3:21 p.m., an observation was made of R90. R90's fingernails on the right hand…

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 assess and monitor a pressure injury for one of 50 residents in the survey sample, Resident #86. The findings include: For Resident #86 (R86), the facility staff failed to document the size and stage of the pressure injury (1) on 5/31/24, when treatment was initiated, and failed to monitor the wound with measurements weekly for healing. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/8/24, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section M - Skin Conditions, R86 was coded as having one stage two (2) pressure injury. The wound care nurse practitioner note dated 5/20/24 documented in part, Sacrum scar tissue. The wound care physician notes dated, 5/31/24, documented in part, Sacrum - stage 2 measuring approximately 1x1x 0.1 cm (centimeters) in size.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, facility staff failed to provide toenail care for one of 50 residents, Resident #56 (R56). The findings include: On the following dates and times was observed with toenails between one and one and half inches long: 7/8/24 at 8:45a.m., 7/9/24 at 9:11a.m., and 7/10/24 at 1:42 p.m. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/4/24. R56 was coded as being dependent for personal hygiene. She was admitted on [DATE] with a diagnosis of traumatic brain dysfunction, seizure disorder and diabetes mellitus. A review of R56's care plan revealed, Personal hygiene care/Oral Care: The resident requires total assistance of 2x assist .Assist with all cares/ADLs On 7/11/24 at 10:008 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated that residents receive nail care every day. She stated that if the resident is diabetic then the podiatrist will cut and do toenail care. On 7/11/24…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and facility document review, the facility staff failed to apply splints for one of 50 residents, Resident #56. Findings include: For Resident #56 (R56), the facility staff failed to apply right- and left-hand splints. On the following dates and times, R56 was observed in bed. Left-and right-hand splints were not visible on the resident: 7/8/24 at 3:20 p.m.; 7/9/24 at 9:15 a.m.; and 7/10/24 at 10:15 a.m. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/4/24. R56 was coded as having functional limitation in range of motion. She has an upper extremity impairment on both sides. She was admitted on [DATE] with a diagnosis of traumatic brain dysfunction, seizure disorder, persistent vegetative state and diabetes mellitus. A review of R56's care plan revealed, in part: Nursing/Rehab Restorative: Splint. PROM (passive range of motion) first then apply splint. See pictures for BUE (bilateral upper extremity) splints…

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, clinical record review and facility document review, it was determined that the facility staff failed to maintain a urinary catheter bag in a sanitary manner for one of 50 residents in the survey sample, Resident #89. The findings include: 1. For Resident #89 (R89), the facility staff failed to maintain a urinary catheter collection bag in a sanitary manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/18/24, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section H coded R89 having an indwelling catheter. On 7/9/24 at 9:05 a.m., an observation was made of R89 in their room. R89 was observed lying in bed with a catheter bag hanging off of the right side of the bed frame. The catheter bag was observed to be touching the floor. At that time an interview was conducted with R89 who stated that the staff took care of the catheter and they did not…

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

Based on observation, staff interivew, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services for two of 50 residents in the survey sample, Residents #56 and #13. The findings include: 1. For Resident #56 (R56), the facility staff failed to administer oxygen at the physician prescribed rate of five liters per minute. R 56's comprehensive care plan revised on 6/22/21 documented, Oxygen administered as ordered .Further review of R56's clinical record revealed a physician's order dated 06/14/2024 for oxygen at five liters w/ 28% humidification via trach every day and night shift. On 7/8/24 at 3:00 p.m. and 3/9/24 at 3:18 p.m. and 7/10/24 at 9 p.m., R56 was observed lying in bed receiving oxygen via trach at two and a half liters per minute, as evidenced by the middle of the ball in the oxygen concentrator flowmeter positioned on the two-and-a-half line. On 7/11/24 at 10:23 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN#2 stated that nurses should know how much oxygen to administer…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility document review, and clinical record review, the facility staff failed to act on a pharmacy recommendation for one of 50 residents in the survey sample, Resident #79. The findings include: For Resident #79 (R79), the facility staff failed to act on a pharmacy recommendation dated 4/24/24 to discontinue PRN (as needed) use of the anti-psychotic medication Zyprexa (1). A review of R79's clinical record revealed a physician's order dated 4/1/24 for Olanzapine (Zyprexa) 2.5 mg (milligrams) by mouth every 24 hours as needed. A pharmacy recommendation dated 4/24/24 documented, Recommend discontinue PRN use of ZYPREXA for agitation. The use of an antipsychotic medication for 3 or less days does not allow adequate time for the medication to reach therapeutic antipsychotic levels and is primarily used for its sedative/anti-anxiety effects. Suggest considering the use of a medication from a different therapeutic class such as a short acting benzodiazepine for PRN use with 14 day stop.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary psychotropic medication for one of 50 residents in the survey sample, Resident #79. The findings include: For Resident #79 (R79), the facility staff failed to ensure the physician or prescribing practitioner evaluated the resident for continued use of the as needed antipsychotic medication Olanzapine (1) and documented the rationale for the continued use. A review of R79's clinical record revealed a physician's order dated 4/1/24 for Olanzapine (Zyprexa) 2.5 mg (milligrams) by mouth every 24 hours as needed for terminal delirium related to dementia. A review of R79's June 2024 revealed the resident received as needed Olanzapine on 6/5/24. On 7/10/24 at 3:03 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated as needed antipsychotic medications should only be ordered for up to 14 days but R79 was having hallucinations 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 and facility document review it was determined facility staff failed to secure Medications in a safe and secure manner according to professional standards for two of 50 residents, Resident #32 and Resident #159. The findings include: 1. The facility staff failed to ensure medications were locked. During the initial resident observation on 7/8/24 at approximately 12:45 PM, upon entrance to Resident #32's room, a bottle of Nystatin powder was observed on bedside table. The Nystatin powder was labeled for another resident. Resident #32 was not in the room at the time. At approximately 3:15 PM Resident #32 was in room, when asked about the Nystatin powder with the other resident's name, Resident #32 stated, no, I did not notice the bottle on the dresser. Resident #32 was admitted to the facility on [DATE] with diagnosis that included but were not limited to ASCVD (atherosclerotic cardiovascular disease), CKD (chronic kidney disease) and CHF (congestive heart failure). The most…

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 perform a bed inspection for two of 50 residents in the survey sample, Residents #86 and #124. The findings include: 1. For Resident #86, the facility staff failed to inspect the resident's bariatric bed for safety and entrapment. Resident #86 was observed on 7/8/24 at approximately 12:00 p.m. in bed, with two half side rails on each side of the bed. The physician order dated, 5/18/24, documented, BB (bariatric bed) bed with 1/2 side rails. The review of the bed inspection book documented the bed in the room was not the same as the current bed in the room. There was no bed inspection for the bariatric bed in use. An interview was conducted with OSM (other staff member) #18, the director of maintenance on 7/10/24 at 2:11 p.m. When asked the process to ensure the bariatric beds are inspected for safety and entrapment, OSM #18 stated if there is a bariatric bed need, we place it i the room but only on the B side of the room. We do an inspection…

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 document review, it was determined that the facility staff failed to ensure QAPI (quality assurance and performance improvement) program training was completed for one of five employees reviewed, OSM (other staff member) #5. The findings include: For OSM #5, a floor technician, the facility staff failed to ensure training regarding the facility QAPI program was completed. OSM #5 was hired on 6/1/23. The facility staff failed to provide evidence that OSM #5 had completed training regarding the facility QAPI program. On 7/11/24 at 10:52 a.m., an interview was conducted with ASM (administrative staff member) #4, the regional vice president of operations. ASM #4 stated that OSM #5 was set to have the QAPI training added to their computer based training program in August. He stated that they do a general orientation but was not sure if QAPI training was put in the system upon hire or not. He stated that he would look further to see if there was anything more to provide. 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 staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide care and service for a complete dialysis program for one of 55 residents in the survey sample, Residents #87 (R87). The findings include: For (R87) the facility staff failed to provide dialysis communication forms for (R87's) dialysis visits on 08/03/2022, 08/05/2022, 08/10/2022, 08/15/2022, 08/17/2022, 08/19/2022, 08/31/2022 and failed to complete dialysis communication forms on 08/12/2022, 08/22/2022, 08/24/2022, 08/26/2022, 08/29/2022, 09/05/2022, 09/09/2022 and on 09/12/2022. (R87) was admitted to the facility with diagnoses included but were not limited to: end stage renal failure (1). On the most recent MDS (minimum data set), a 5-Day assessment with an ARD (assessment reference date) of 08/01/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R87) for Dialysis while 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.

Based on observation, staff interview, and facility document review it was determined facility staff failed to store food in a sanitary manner in one of one facility kitchens. 1. The facility staff failed to seal one 13.9 ounce package of dry gravy mix in one of one dry food storage rooms. 2. The facility staff failed to close a box containing one frozen pie and seal a package of frozen cookie dough in one of one walk-in freezers. The findings include: On 09/13/22 at approximately 10:45 a.m., an observation of the facility's kitchen was conducted with OSM (other staff member) #1, dietary manager. 1. At approximately 10:50 a.m., an observation of the facility's dry storage room revealed a 13.9 ounce package of dry gravy mix sitting on a shelf. Observation of the package revealed that it was opened to the environment. When asked how much of the dry gravy mix was remaining in the package, OSM # 1 stated that there was approximately half of the product remaining in the package. 2. At approximately 11:00 a.m., an observation of the facility's walk-in freezer revealed a box containing 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.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to determine if a resident had an Advance Directive for one of 55 residents in the survey sample, Resident #110 (R110). The findings include: On the most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date of 8/11/2022, the resident scored a 5 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired for making daily decisions. The physician orders dated 8/4/2022, documented, DNR (do not resuscitate). Further review of the clinical record failed to evidence documentation of a discussion regarding an advance directive for R110. A request was made on 9/13/2022 at 5:00 p.m. for the documentation related to the advance directive discussion with the resident and/or responsible party. On 9/14/2022 at 8:00 a.m., ASM (administrative staff member) #1, the administrator, stated the facility did not have any documentation related to R110's advance…

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 the facility staff failed to respect the resident's right to privacy for one of 55 residents, Resident #467. The findings include: The facility staff failed to respect the resident's right to privacy by keeping the privacy curtain closed for Resident #467. The privacy curtain was observed to be pulled back halfway between the two beds on 9/13/22 at 11:00 AM, again at 1:00 PM and the roommate was seated between the two beds with the privacy curtain behind her wheelchair watching TV at approximately 3:00 PM. Resident #467 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: cerebral vascular infarction, COPD (chronic obstructive pulmonary disease), atrial fibrillation and diabetes. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 9/9/22, coded the resident as scoring a 99 out of 15 on the BIMS (brief…

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 the facility staff failed to implement the comprehensive care plan for 2 of 55 residents in the survey sample; Residents #146 and #82. The findings include: 1. For Resident #146, the facility staff failed to implement the comprehensive care plan for the use of fall mats. Resident #146 was admitted to the facility on [DATE]. The most recent MDS (Minimum Data Set), an annual assessment dated [DATE] coded the resident as being severely cognitively impaired in ability to make daily life decisions. A review of the clinical record revealed the comprehensive care plan dated 9/12/20 for [Resident #146] has had an actual fall and is at risk for falls r/t (related to) Confusion, Deconditioning, Poor communication/comprehension, Unaware of safety needs and included the intervention, dated 9/13/20 for assistive Devices: assist bars to bed, geri chair, fall mats, low bed, concave mattress. A review of the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to provide care and services to maintain a resident's highest level of well-being for one of 55 residents in the survey sample, Resident #367. The facility staff failed to ensure Resident #367's (R367) high white blood cell count (1) result was addressed by the nurse practitioner on 7/8/22. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/29/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. Review of R367's clinical record revealed laboratory results dated [DATE] that documented a high white blood cell count of 10.60 thousand per cubic milliliter (with a reference range of 4.1-10.9) and a urine culture that documented urine bacteria. An antibiotic was initiated for R367 on 6/30/22. A note…

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 that the facility staff failed to provide treatment to a pressure ulcer in a sanitary manner for one of 55 residents in the survey sample, Resident #107 (R107). For R107, the nurse providing wound care failed to wash/sanitize hands between glove changes (between dirty and clean parts of the procedure). The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/5/22, R107 was coded as being in a persistent vegetative state. R107 was coded as having no pressure ulcers during the look back period. On 9/14/22 at 10:59 a.m., RN (registered nurse) #3 was observed as she provided wound care to R107. RN #3 removed the old dressing from the top of R107's right foot wound. RN#3 cleansed the wound with wound cleanser, and wiped the wound with dry gauze. RN #3 threw the soiled gauze in the trash can, removed her dirty gloves and put on a clean pair of gloves. RN #3 did not wash/sanitize her hands between removing…

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 the facility staff failed to implement interventions to prevent accidents and hazards for one of 55 residents in the survey sample; Resident #146. The findings include: For Resident #146, the facility staff failed to follow physician's orders for the use of fall mats. Resident #146 was admitted to the facility on [DATE]. The most recent MDS (Minimum Data Set), an annual assessment dated [DATE] coded the resident as being severely cognitively impaired in ability to make daily life decisions. A review of the clinical record revealed a physician's order dated 9/29/20 for Low bed and fall mats. On 9/13/22 at 11:46 AM, the resident was observed in bed asleep. The bed was in low position. There was a fall mat on the resident's left side, but on the right side, the fall mat was folded up, leaning against the wall. A review of the clinical record revealed the comprehensive care plan dated 9/12/20 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 observation, staff interview, facility document review and clinical record review, the facility staff failed to provide respiratory care and services per the plan of care for one of 55 residents in the survey sample, Resident #82. For Resident #82 (R82), the facility staff failed to administer to oxygen at the physician prescribed rate of 3 liters per minute. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/29/22, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. A review of R82's clinical record revealed a physician's order dated 7/1/22 for oxygen at 3 liters per minute. R82's comprehensive care plan revised on 7/1/22 documented, (R82) has Congestive Heart Failure. O2 (Oxygen) as ordered. On 9/13/22 at 4:03 p.m. and 9/14/22 at 7:56 a.m., R82 was observed lying in bed receiving oxygen at three and a half liters per minute as evidenced by the middle of the ball in the 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, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure the nurse practitioner and/or physician supervised the residents care for one of 55 residents in the survey sample, Resident #367. The covering nurse practitioner failed to address Resident #367's (R367) reported high white blood cell count (1) on 7/8/22 when reported by the laboratory. The findings include: On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/29/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. A review of R367's clinical record revealed the resident was assessed by a nurse practitioner on 6/23/22, 6/24/22, 6/28/22, 6/29/22, 6/30/22, 7/1/22, 7/5/22, 7/6/22 and 7/7/22. Further review of R367's clinical record revealed laboratory results dated [DATE] that documented a high white blood cell…

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.

2. For R107, the nurse providing wound care failed to follow infection control procedures related to washing/sanitizing hands between glove changes (between dirty and clean parts of the procedure). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/5/22, R107 was coded as being in a persistent vegetative state. R107 was coded as having no pressure ulcers during the look back period. On 9/14/22 at 10:59 a.m., RN (registered nurse) #3 was observed as she provided wound care to R107. RN #3 removed the old dressing from the top of R107's right foot wound. RN#3 cleansed the wound with wound cleanser, and wiped the wound with dry gauze. RN #3 threw the soiled gauze in the trash can, removed her dirty gloves and put on a clean pair of gloves. RN #3 did not wash/sanitize her hands between removing the dirty gloves and putting on the clean gloves. RN #3 repeated this same process when she removed the old dressing from R107's right heel wound, cleansed the wound with wound cleanser, wiped the wound with dry gauze, disposed of her…

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 the facility staff failed to determine and document the pneumococcal vaccination status for two of five residents in the infection control review, Residents #128 and #218. The findings include: 1. For Resident #128 (R128), the facility staff failed to determine and document the pneumococcal vaccination status. On the most recent MDS (minimum data set) assessment, a Medicare five day assessment, with an assessment reference date (ARD) of 8/16/2022, the resident scored a 6 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions. In Section 0 - Special Treatments, Procedures and Programs, was coded as having not assessed or no information was available to code the MDS for the resident's pneumococcal vaccination status. Review of the clinical record failed to evidence documentation of R128's pneumococcal vaccination status. 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 2. The facility staff failed to maintain a functioning call bell system for Resident #217 (R217). There was no MDS (minimum data set) assessment completed at the time of survey. The Admission/readmission Nursing Collection Tool dated 9/6/2022, documented in part, R217 was cognitively intact. During the resident interview on 9/13/2022 at approximately 11:30 a.m. R217 stated it takes a long time for the staff to answer the call bell. Observation was made of the call bell on 9/13/2022 at approximately 1:30 p.m. The call bell was turned on by one surveyor. The other surveyor observed that the call light outside the room did not turn on. An interview was conducted with LPN (licensed practical nurse) #8 on 9/13/2022 at 1:49 p.m. When asked if a resident's call bell is not working, how does the staff know when the need assistance, LPN #8 stated they make constant rounds. When asked if the call bell system rings at the nurse's station, LPN #8 showed the monitor at the nurse's station. The monitor was not functioning 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 and clinical record review, it was determined that facility staff failed to promote resident's dignity for three of 33 current residents in the survey sample, Resident's # 26, #141 and #108. The facility staff were observed standing while feeding Resident #26 and Resident #141. The facility staff failed to provide privacy for Resident # 108's catheter collection bag [1]. The findings include: 1. Facility staff stood next to Resident # 26 while they fed them their lunch and breakfast. Resident # 26 was admitted to the facility with diagnoses that included but were not limited to: swallowing difficulties, muscle weakness and high blood pressure. Resident # 26's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/03/2021, coded Resident # 26 as scoring a 7 [seven] on the brief interview for mental status (BIMS) of a score of 0 - 15, seven - being moderately impaired of cognition for making daily decisions. Resident # 26 was coded as requiring extensive assistance of one staff member for eating.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to implement the comprehensive care plan for the use of TED hose for one of 33 residents in the survey sample, Resident #42. The findings include: Resident #42 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD) (2) and diabetes (3). Resident #42's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/10/2021 coded Resident #42 as scoring an eight on the staff assessment for mental status (BIMS) of a score of 0 - 15, 8- being moderately impaired for making daily decisions On 5/17/2021 at approximately 1:10 p.m., an observation was conducted of Resident #42 in their room. Resident #42 was observed lying in bed. Resident #42 was observed not wearing TED (1) hose and was observed wearing red anti-slip socks on their feet. An additional…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review it was determined that the facility staff failed to follow professional standards of practice for one of nine residents in the medication administration observation, Resident #30. The facility staff failed to follow medication administration standards of practice during the administration of a Dulera Aerosol inhaler to Resident #30 on 5/17/2021. The findings include: Resident #30 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD) (2) and dementia (3). Resident #30's most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 3/1/2021 coded Resident #30 as scoring an 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. On 5/17/2021 at approximately 4:49 p.m., an observation of medication administration for Resident #30 was conducted with LPN (licensed…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to follow the physician's order for the use of TED hose for one of 33 residents in the survey sample, Resident #42. The findings include: Resident #42 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD) (2) and diabetes (3). Resident #42's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/10/2021 coded Resident #42 as scoring an eight on the staff assessment for mental status (BIMS) of a score of 0 - 15, 8- being moderately impaired for making daily decisions On 5/17/2021 at approximately 1:10 p.m., an observation was conducted of Resident #42 in their room. Resident #42 was observed lying in bed. Resident #42 was observed wearing red anti-slip socks on their feet and their legs were observed to be bare. An additional…

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 the facility staff failed to provide care and services for a catheter bag for one of 33 residents in the survey sample, Resident #142. Multiple observations of Resident #142 revealed the attached leg bag above the level of the nephrostomy (1) site it was connected to. The findings include: Resident #142 was admitted to the facility with diagnoses that include but were not limited to acute pyelonephritis (2), acute cystitis (3) and hydronephrosis (4). Resident #142's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 3/12/2021 coded Resident #142 as scoring a six on the staff assessment for mental status (BIMS) of a score of 0 - 15, 6- being severely impaired for making daily decisions. Section G coded Resident #142 as totally dependent of one person for toilet use and requiring extensive assistance from one person for bed mobility and 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, clinical record review, and facility document review, it was determined that the facility staff failed to consistent with professional standards of practice, the comprehensive person-centered care plan for two of 33 residents in the survey sample, Residents #38 and #42. 1. The facility staff failed to maintain an Ambu bag [1] at Resident # 38's bed side according to physician's orders. 2. The facility staff failed to store a nebulizer (1) in a sanitary manner for Resident #42. The findings include: 1. Resident # 38 was admitted to the facility with diagnoses that include but not limited to: traumatic brain injury with loss of consciousness [2], respiratory failure [3] and tracheostomy [4]. Resident # 38's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 03/10/2021, coded Resident # 38 as scoring a 3 [three] on the brief interview for mental status (BIMS) of a score of 0 - 15, three - being severely impaired of cognition…

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

Based on observation, resident interview, staff interview and facility document review, it was determined that the facility staff failed to maintain a functional call system for two of 33 residents in the survey sample, Resident #46 and Resident #66. Resident #46 and Resident #66 shared a room with a broken call bell and had no alternate means to call staff when the call bell was not working. The findings include: Resident #46 was admitted to the facility with diagnoses that included but were not limited to chronic kidney disease (1) and diabetes (2). Resident #46's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/11/2021, coded Resident #46 as scoring a 10 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 10- being moderately impaired for making daily decisions. Section G coded Resident #46 as requiring extensive assistance of two or more persons for bed mobility and transfers and extensive assistance from one person for toilet use and personal hygiene. Resident #66 was admitted to the facility with diagnoses…

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.