Highland Ridge Rehab Center

Based on observations, resident interviews, staff interviews, and facility document review, the facility staff failed to address resident concerns regarding food services. The findings included:For the facility, the facility staff failed to adequately address resident complaints about the food. During the course of the survey, multiple resident interviews were conducted and multiple residents complained about the taste and temperature of the food and not having snacks available. A review of Resident Council Minutes dated 12/30/25 read in part, .Residents stated it is a waste of time to voice any concerns with dietary.nothing is getting done.still not receiving snacks A review of Resident Council Minutes dated 1/27/26 read in part, .Residents stated the eggs and vegetables are watery when served.Residents are stating the hot plates are not hot when meals arrive and their food is cold .will send an email to Dietary Manager to follow up with these concerns. A review of Resident Council Minutes dated 2/24/26 read in part, .All residents agree the food is cold when they receive it.All…

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

Based on observation, staff interview and facility document review the facility staff failed to follow established infection control procedures.The findings included:During a medication pass and pour observation, observed the nurse touching medications with her bare hands. For Resident # 42 observed an incentive spirometer under the resident's bed, and for Resident #92, failed to bag CPAP (continuous positive airway pressure) mask. Linens were observed on the floor in room B-6 and A-6, A-bed side.On 02/25/26 at 8:00 am, while preparing to observe a medication pass and pour, registered nurse (RN) #2 was observed dispensing medication from the medication card into her bare hand and placing them in the medication cup. During the medication pass and pour observations, RN #2 removed a capsule from the medication cup with her bare hand, opened it and poured the contents into a cup of pudding.Linens were observed laying on the floor of room B-6 on 02/25/26 at 8:40 am. A wet washcloth was observed laying on the floor of room A-6 on 02/25/26 at 1:20 pm.An incentive spirometer was observed…

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, the facility staff failed to employ an infection preventionist with the required training prior to assumption of the role.The findings included:On 9/5/25, members of the survey team made multiple observations of residents requiring EBP (enhanced barrier precautions) and/or TBP (transmission-based precautions) without proper notification/signage and PPE available to staff, residents and/or visitors. On 9/5/25 at 2:54 PM-surveyors met with interim administrator (ADM), interim director of nursing (DON), regional director of clinical services and licensed practical nurse #1 (LPN#1). This surveyor inquired about the facility IP (infection preventionist) and the DON informed surveyor the previous IP left employment at the facility on 7/4/25 and she and the ADM are acting IPs and both agreed neither of them has an IP certification. LPN#1 has an IP certification from 2022 and she agreed that she does not perform the IP role at the facility. Surveyor requested evidence of staff education on infection control procedures 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, resident interview and facility document review the facility staff failed to provide a reasonable accommodation of needs for 1 of 16 residents, Resident #15.The findings included:For Resident #15 the facility staff failed to answer the resident's call bell in a timely manner. Resident #15's clinical record listed diagnoses which included but not limited to chronic obstructive pulmonary disease, dysphagia, and major depressive disorder.Resident #15's most recent minimum data set with an assessment reference date of 07/17/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact.Surveyor spoke with Resident #15 on 09/05/25 at 11:05 am regarding call bell response times. Resident stated that call bell response has been addressed at resident council meetings, but times never get any better, and they have waited up to an hour after ringing call bell. Resident stated that their call bell is currently on, and they thought surveyor was…

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

Based on staff interview and clinical record review, the facility staff failed to follow the medical provider orders for medication administration for 1 of 16 sampled residents (Resident #6). The findings included:For Resident #6, the facility staff failed to administer the oral medication, Cyclobenzaprine as ordered by the medical provider. Cyclobenzaprine is a muscle relaxant used to treat skeletal muscle conditions such as pain and injury. Resident #6's diagnosis list indicated diagnoses, which included, but not limited to Encephalopathy, Hemiplegia and Hemiparesis, Congestive Heart Failure, Epilepsy, Multiple Rib Fractures Left Side, Fracture of Nasal Bones, Fracture of Left Thumb, and Fracture of Shaft of Left Clavicle. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 1/23/25 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #6's clinical record included a medical provider order for Cyclobenzaprine HCL 10 mg by mouth three times a day for muscle…

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, resident interview, clinical record review and facility document review the facility staff failed to follow and established infection control program for 3 of 10 residents, Resident #15, Resident #12, and Resident #16.The findings included:1.For Resident #15 the facility staff failed to provide and don personal protective equipment (PPE) while providing incontinence care. Resident #15's clinical record listed diagnoses which included but not limited to personal history of urinary (tract) infections and resistance to multiple antimicrobial drugs. Resident #15's most recent minimum data set with an assessment reference date 07/17/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #15's comprehensive care plan was reviewed and contained a plan for ISOLATION: the resident requires Enhanced Barrier precautions (EBP) due to colonization of MDRO (multi drug-resistant organism). Interventions for this plan include…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to provide Activity of Daily Living (ADL) care for 5 of 18 dependent care residents, Resident's #2, #1, #12, #13 and #17. The findings included: 1. For Resident #2, the facility staff failed to provide ADL care regarding bathing. Resident #2 was at the facility for 21 days. During this 21 day timeframe the facility staff documented the resident had received 1 shower. This was a closed record review. Resident #2's diagnoses included, but were not limited to, Alzheimer's disease, muscle weakness, depressive disorder, and dementia. Section C (cognitive patterns) of Resident #2's admission minimum data set (MDS) assessment with and assessment reference date (ARD) of 11/02/23 included a brief interview for mental status (BIMS) score of 3 out of a possible 15 points. Section GG (functional abilities and goals) was coded to indicate Resident #2 was dependent in the area of shower/bathe self. Resident #2's comprehensive care plan included the focus area has ADL care…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure the residents call system was within reach for 1 of 13 current residents, Resident #1. The findings included: The facility staff failed to ensure Resident #1's call system was in reach. Resident #1 was observed up in their wheelchair the call system was placed on the bed and out of reach of this resident. Resident #1's diagnoses included, but were not limited to, repeated falls, diabetes, hearing loss, and difficulty in walking. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/28/23 included a brief interview for mental status (BIMS) summary score of 14 out of a possible 15 points. Resident #1's comprehensive care plan included the interventions encourage the resident to use bell to call for assistance, ensure/provide a safe environment, and call light in reach. On 01/02/24 at 10:59 a.m., two surveyors observed Resident #1 up in their wheelchair in their room. Resident #1's…

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

Based on observation and staff interview the facility staff failed to ensure a clean, comfortable, and homelike environment for 1 of 13 current residents, Resident #17. The findings included: For Resident #17 the facility staff failed to ensure a clean environment. Resident #17's face sheet listed diagnoses which included but not limited to adult failure to thrive and other specified disorders of the skin and subcutaneous tissues related to radiation. Resident #17's most recent minimum data set with an assessment reference date of 10/13/23 assigned the resident brief interview for mental status score of 5 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Surveyor observed Resident #17 in his room on 01/03/24 at 4:30 pm. Resident was resting in bed with family member at bedside. Resident's room was clean in appearance at this time. Surveyor asked resident and family member if room was cleaned regularly, and family member stated that at times there was debris (food scraps) on the floor when they came to visit. Surveyor…

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

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow up on a grievance for 1 of 5 closed record reviews, Resident #2. The findings included: The facility staff failed to follow up on a grievance filed by the Resident #2's Responsible Party (RP). Resident #2's diagnoses included, but were not limited to, Alzheimer's disease, muscle weakness, depressive disorder, and dementia. Section C (cognitive patterns) of Resident #2's admission minimum data set (MDS) assessment with and assessment reference date (ARD) of 11/02/23 included a brief interview for mental status (BIMS) score of 3 out of a possible 15 points. On 01/02/24 at 4:05 p.m., the surveyor requested from the Social Worker (SW) any grievances regarding Resident #2. The SW stated they had taken a grievance from the family of this resident; they had given the grievance concerns to the Director of Nursing (DON) who gave it to the previous Unit Manager. The SW stated this grievance was not followed up on. The SW provided the surveyor a copy of this form. The section…

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

Based on resident interview, staff interview, clinical record review and facility document review the facility staff failed to follow professional standards of practice for the administration of medications for 1 of 13 current residents, Resident #14. The findings included: For Resident #14 the facility staff documented medications as administered when they were not. Resident #14's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, pain in unspecified joint, and chronic pain syndrome. Resident #14's most recent minimum data set with an assessment reference date of 10/16/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Surveyor spoke with Resident #14 on 01/03/23 at 4:45 pm. Surveyor asked Resident #14 if they ever had any problems getting their scheduled medications, and resident stated the nurse practitioner was supposed to be ordering them a pain patch and some ointment for pain, but the nurse had told them that it hadn't…

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

Based on staff interview, clinical record review and facility document review the facility staff failed to follow physician's orders for 1 of 13 current residents, Resident #14. The findings included: For Resident #14 the facility staff failed to follow physician's orders for the administration of the medication gabapentin. Resident #14's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, pain in unspecified joint, and chronic pain syndrome. Resident #14's most recent minimum data set with an assessment reference date of 10/16/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #14's comprehensive care plan was reviewed and contained a care plan for the resident has acute and chronic pain r/t (related to) Lt (left) BKA (below knee amputation), Morbid Obesity, Neuropathy, Osteoarthritis, Gout. Interventions for this care plan include Administer analgesia as per orders. Resident #14's clinical record was reviewed 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 staff interview and clinical record review the facility staff failed to ensure medications were available for administration for 1 of 13 current residents, Resident #14. The findings included: For Resident #14 the facility staff failed to ensure the medications gabapentin and methadone were available for administration. Resident #14's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, pain in unspecified joint, and chronic pain syndrome. Resident #14's most recent minimum data set with an assessment reference date of 10/16/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #14's comprehensive care plan was reviewed and contained a care plan for the resident has acute and chronic pain r/t (related to) Lt (left) BKA (below knee amputation), Morbid Obesity, Neuropathy, Osteoarthritis, Gout. Interventions for this care plan include Administer analgesia as per orders. Resident #14's clinical record was reviewed…

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

Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure 1 of 13 current residents was free of significant medication error, Resident #14. The findings included: For Resident #14 the facility staff failed to administer the antibiotic medication, Cefepime per the physician's orders. Resident #14's face sheet listed diagnoses which included but not limited to type 2 diabetes mellitus, pain in unspecified joint, and chronic pain syndrome. Resident #14's most recent minimum data set with an assessment reference date of 10/16/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Resident #14's clinical record was reviewed and contained a physician's order summary which read in part, Cefepime HCl Injection Solution Reconstituted 1 GM (gram) (Cefepime HCl). Use 1 gram intravenously every 8 hours to wound infection for 7 days -Start Date- 08/30/2023. Resident #14's electronic medication administration record for the…

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

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to assist residents in obtaining dental care from an outside source for 1 of 13 current residents in the survey sample, Resident #15. The findings included: For Resident #15, the facility staff delayed scheduling a dental consult for three (3) months and failed to obtain an appointment with an oral surgeon as requested by the referring dentist. Resident #15's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus, Congestive Heart Failure, Chronic Kidney Disease Stage 2, and Chronic Obstructive Pulmonary Disease. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 10/12/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. On 1/03/24 at 4:30 PM, surveyor spoke with Resident #15 who stated they had a fall in the bathroom when the support bar gave way and fell from the wall causing them to…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to operate in compliance with all applicable Virginia state regulations as evidenced by failing to determine if a potential resident was a registered sex offender prior to admission for 1 of 13 current residents in the survey sample, Resident #8. The findings included: According to Virginia Code 12VAC5-371-150 (H): Prior to admission, each nursing facility shall determine if a potential resident is a registered sex offender when the potential resident is anticipated to have a length of stay: 1. Greater than three days; or 2. In fact stays longer than three days. For Resident #8, the facility staff verified the resident's sex offender status six days following admission to the facility. Resident #8's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side, Adult Failure to Thrive, Chronic Obstructive Pulmonary…

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 maintain a complete and accurate clinical record for 1 of 13 current residents, Resident #1. The findings included: Resident #1's clinical record included conflicting information regarding their current code status. Resident #1's diagnoses included, but were not limited to, repeated falls, diabetes, hearing loss, and difficulty in walking. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) summary score of 14 out of a possible 15 points. Resident #1's clinical record included the following documents: Face sheet that included the documentation CPR. Physician orders dated [DATE] code status was CPR. A DDNR order form dated [DATE] indicating the resident was a DNR (do not resuscitate). Progress note dated [DATE] and signed by the Nurse Practitioner (NP) documenting Resident #1's code 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.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to follow established infection control guidelines for 2 of 13 current residents, Resident #1 and #13. The findings included: 1. For Resident #1, the surveyor observed dirty linen in the floor of Resident #1's bathroom. Resident #1's diagnoses included, but were not limited to, repeated falls, diabetes, hearing loss, and difficulty in walking. Section C (cognitive patterns) of Resident #1's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/28/23 included a brief interview for mental status (BIMS) summary score of 14 out of a possible 15 points. On 01/02/24 at 10:59 a.m., the surveyor observed dirty linen in the corner of Resident #1's bathroom. This resident was in a private room. On 01/02/24 at 12:13 p.m., during a second observation the surveyor again observed the dirty linen in the bathroom floor. On 01/02/24 at 1:30 p.m., the dirty linen was observed to remain in the bathroom floor. On top of the linen…

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 resident interview the facility staff failed to ensure a clean, comfortable, homelike environment for 1 of 4 shower rooms in the facility. The findings included: For the shower room on C-wing of the facility, there was an odor of urine and mildew, a cabinet labeled Keep cabinet locked at all times!!! was found unlocked, shampoo and body wash were lying on the shower stretcher, and a shoe was lying in the bathroom floor. On 04/24/23 at 3:15 pm, surveyor interviewed Resident #62. Resident #62 stated to surveyor that the shower room on C-wing was dirty and smells like mildew. Resident #62's most recent minimum data set with an assessment reference date of 03/10/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Surveyor observed the shower room on C-wing on 04/25/23 at 1:35 pm. Surveyor noted a strong odor of urine in the shower room at this time. Surveyor observed the shower room on C-wing on 04/26/23 at 8:30 am. Surveyor…

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, resident interview, clinical record review, and facility document review, the facility staff failed to develop and implement a comprehensive person-centered care plan to meet the needs of the resident for 1 of 26 residents in the survey sample. The findings include: For resident #376, the facility staff failed to develop a care plan to address pressure ulcer risk and wound care. Resident #376 diagnoses included, but were not limited to, congested heart failure, chronic obstructive pulmonary disease, cellulitis of the left lower limb, atrial fibrillation, pneumonia and malnutrition. The admission Minimum Date Set Assessment (MDS), with an Assessment Reference Date (ARD) of 4/12/23 assigned the resident a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 indicating that resident #376 was cognitively intact. Resident #376 was coded in section G of the MDS as requiring extensive assistance of one or two people with bed mobility, transfers, toileting and personal hygiene. In section H of the MDS, resident #376 was coded as…

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

Based on staff interview, resident interview, clinical record review and facility document review the facility staff failed to follow professional standards of practice for physician notifications and documentation of medications and/or treatments for 2 of 26 residents, Resident #99, and Resident #376. The findings included: 1. For Resident #99 the facility staff failed to notify the physician and document medication refusals in the clinical record. Resident #99's face sheet listed diagnoses which included but not limited to type II diabetes mellitus. The most recent minimum data set with an assessment reference date of 03/01/23 assigned the resident a brief interview for mental status score of 14 out of 15 in section C, cognitive status. This indicates that the resident is cognitively intact. Resident #99's comprehensive care plan was reviewed and contained a care plan for the resident has Diabetes Mellitus. Interventions for this care plan included Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #99's clinical record was…

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

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to develop and implement an effective discharge planning process for 1 of 4 residents in the closed record sample. The findings include: For resident #325, the facility staff failed to involve the resident representative in the development of the discharge plan and inform the resident representative of the final plan to transfer the resident to another facility. Resident #325's diagnoses included but were not limited to unspecified dementia, insomnia, anxiety disorder, macular degeneration, hypertension and muscle weakness. The most recent Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 1/24/23 assigned resident #325 a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. The MDS also revealed that resident had no signs or symptoms of delirium and no behavior symptoms during the assessment review period. Resident #325 was documented as requiring supervision to limited assistance with 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 clinical record review, facility document review and staff interviews, the facility staff failed to complete a discharge summary for one of 4 residents in the closed record sample. The findings include: For resident #325 the facility staff failed to complete a discharge summary that included a recapitulation of the resident's stay, diagnoses, course of illness/treatment, a summary of the resident's status, reconciliation of all medications, a post-discharge plan of care developed with the participation of the resident and/or resident representative. Resident #325's diagnoses included but were not limited to unspecified dementia, insomnia, anxiety disorder, macular degeneration, hypertension and muscle weakness. The most recent Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 1/24/23 assigned resident #325 a Brief Interview for Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. The MDS also revealed that resident had no signs or symptoms of delirium and no behavior symptoms during the assessment review period.…

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 interviews, clinical record review, and facility document review the facility staff failed to ensure residents received treatment and care in accordance with provider orders and the comprehensive person-centered care plan for 2 of 26 current residents, Resident #88 and #66. The findings were: 1. Facility staff failed to ensure Resident #88 received a medication, Gabapentin, on 3/22/23 and 3/23/23 as scheduled per a provider order. Resident #88's face sheet listed diagnoses included but were not limited to spinal stenosis, chronic pain, scoliosis, low back pain, osteoarthritis, fibromyalgia, and post laminectomy syndrome. The minimum data set with an assessment reference date of 01/19/23 coded the resident's brief interview for mental status a 15 out of 15 in Section C (cognitive patterns). Resident #88's clinical record included a provider's order for Gabapentin Capsule 100 mg by mouth at bedtime for pain. The medication order started on 12/13/22. Upon meeting…

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 interviews and facility document review, the facility staff failed to ensure a registered nurse was working at the facility for two (2) of 30 days reviewed for nursing staffing. The findings include: The facility staff failed to have a registered nurse (RN) working at the facility for the following two days: 4/8/23 and 4/22/23. Review of the facility's posted staffing information forms failed to show a RN working at the facility on the following four (4) days: 4/4/23, 4/8/23, 4/14/23, and 4/22/23. The administrator was able to provide evidence of a RN working on 4/4/23 and 4/14/23. On 4/25/23 at 3:37 p.m., the Administrator reported no RN was working at the facility on 4/8/23 and 4/22/23; the Administrator reported an RN should have been working at the facility on those days. On 4/25/23 at 3:50 p.m., the Director of Nursing (DON) confirmed the aforementioned dates did not have a RN coverage; the DON stated it could have been due to a call out. On 4/26/23 at 4:17 p.m., the survey team met with the Administrator, Director of Nursing, and Assistant Director Nursing. The…

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

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure a medical provider approved medication regimen review (MRR) recommendation was implemented for one (1) of five (5) residents sampled for MRRs. The MRR recommendation had to be requested by the pharmacist a second time prior to it being implemented. The findings include: The facility staff failed to perform and/or implement monitoring for abnormal movements as recommended by a pharmacist, as part of Resident #108's MRR dated 12/10/23. This MRR was signed by a medical provider with the request to add AIMS to nursing tasks. (The Abnormal Involuntary Movement Scale (AIMS) is used to evaluate/monitor individuals who are receiving medications whose side effect include abnormal body movements.) Resident #108's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 4/9/23, was signed as completed on 4/17/23. Resident #108 was assessed as sometimes being able to make self understood and as sometimes being able to understand others. Resident #108's 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.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 26 residents in the survey sample, Resident #78. The findings included: For Resident #78, the facility staff failed to perform a flu test as ordered by the medical provider. Resident #78's diagnosis list indicated diagnoses, which included, but not limited to Dementia, Chronic Kidney Disease Stage 5, Essential Hypertension, and Type 2 Diabetes Mellitus. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 2/09/23 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating the resident was severely cognitively impaired. A review of Resident #78's clinical record revealed a nursing progress note dated 4/10/23 at 5:56 pm which read in part This nurse was called to the dining room by CNA [certified nursing assistant] staff while attempting to assist resident in eating [their] dinner. Staff report increased lethargy. VS [vital…

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 interviews, clinical record review, and facility document review, the facility staff failed to maintain complete and/or accurate clinical record/documentation for three (3) of 26 sampled current residents (Resident #25, Resident #105, and Resident #108). The findings include: 1. Documentation of a resident-to-resident altercation involving Resident #105 was noted to be incomplete and/or accurate. Resident #105's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 1/16/23, was signed as completed on 1/23/23. Resident #105 was documented as able to make self understood and as able to understand others. Resident #8's Brief Interview for Mental Status (BIMS) summary score was documented as an eight (8) out of 15; this indicated moderate cognitive impairment. Resident #105 was documented as requiring assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #105's clinical documentation included a progress note with an effective date and time of 4/14/23 at 9:49 a.m. This note indicated Resident #105 had allegedly…

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

Based on observations, staff interviews, and document review, the facility staff failed to ensure gloves were worn by a staff member when completing a finger stick blood sugar (FSBS) test for one (1) of 26 sampled current residents (Resident #58). The findings include: On 4/25/23 at 9:05 a.m., Licensed Practical Nurse (LPN) #2 was observed to perform a FSBS test for Resident #58 without wearing gloves. LPN #2 confirmed they should have been wearing gloves. Resident #58's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 4/5/23, was dated as completed on 4/7/23. Resident #58 was assessed as able to make self understood and as able to understand others. Resident #58's Brief Interview for Mental Status (BIMS) summary score was documented as a 13 out of 15; this indicated intact and/or borderline cognition. Resident #58 was assessed as requiring assistance with bed mobility, transfers, dressing, eating, and personal hygiene. Resident #58's diagnoses included diabetes. The following information was found in a facility document titled Point Of Care Devices…

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

Based on observation, staff interview and facility document review the facility staff failed to properly store and label medications for 1 of 7 medication carts and dispose of expired medications for 1 of 7 medication carts and 1 of 4 medication rooms. The findings included: For medication cart on C-wing, the facility staff failed to ensure insulin pen was labeled with an opened on date and failed to dispose of an expired bottle of aspirin and an expired bottle of Super B complex. For the medication room on A-wing, the facility staff failed to dispose of expired Afluria Quadrivalent flu vaccine. Surveyor observed the medication cart on C-wing, along with LPN (licensed practical nurse) #1, on 10/07/21 at 1:30 pm. Surveyor observed an opened Novolog insulin pen in the top drawer of the cart. The insulin pen was not labeled with an opened on date. Surveyor asked LPN #1 how they knew how long the pen had been in use and when to discard, and LPN #1 stated there was no way to know without a date, and that they would dispose of pen and get a new one. Surveyor also observed a bottle 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 resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurately documented clinical record for 4 of 25 residents in the survey sample, Resident #19, #87, #108, and #74. The findings included: 1. For Resident #19, the facility staff failed to document treatments provided to the resident's buttocks and upper back. Resident #19's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction Unspecified, Hemiplegia Unspecified Affecting Left Non-dominant Side, Parkinson's Disease, Acute Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, and Chronic Obstructive Pulmonary Disease Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. Resident #19's current physician's orders included an active…

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 the facility staff failed to protect personal privacy for 1 of 25 residents, Resident #48. The findings included: For Resident #48 the facility staff failed to protect the resident's personal privacy while toileting. Resident #48's face sheet listed diagnoses which included but not limited to asthma, arthritis, depression, anxiety, type II diabetes, gout, morbid obesity, and hypertension. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 07/29/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section G, functional status, coded the resident as needing extensive assistance of one person in the area of toileting. Surveyor observed Resident #48 from hallway on 10/06/21 at 2:30 pm. Resident was seated on bedside commode. The privacy curtain was not pulled, the door to the resident's room was open. Resident's roommate was lying on…

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

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 2 of 25 residents in the survey sample, Resident #76 and #74. The findings included: 1. For Resident #76, the facility staff failed to revise the care plan for the use of a hand bell. Resident #76's diagnosis list indicated diagnoses, which included, but not limited to Schizoaffective Disorder Bipolar Type, Chronic Obstructive Pulmonary Disease Unspecified, Chronic Viral Hepatitis C, and Dysphagia following Unspecified Cerebrovascular Disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/30/21 assigned the resident a BIMS (brief interview for mental status score) of 13 out of 15 in section C, Cognitive Patterns. A review of Resident #76's current comprehensive person-centered care plan on 10/07/21 revealed a focus area stating (Resident #76) uses psychotropic medications r/t (related to) Behavior management, hallucinations - Hears voices telling…

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

Based on resident interview, staff interview, and clinical record review, the facility staff failed to ensure that residents who are unable to carry out ADLs (activities of daily living) receive the necessary care and services to maintain personal hygiene and grooming for 1 of 25 residents in the survey sample, Resident #19. The findings included: For Resident #19, the facility staff failed to provide assistance with bathing per the resident's preference of twice weekly. Resident #19's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction Unspecified, Hemiplegia Unspecified Affecting Left Non-dominant Side, Parkinson's Disease, Acute Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, and Chronic Obstructive Pulmonary Disease Unspecified. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 7/06/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. In section G, Functional Status, Resident #19 was coded as being…

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

Based on staff interview and clinical record review, the facility staff failed to follow physician's orders for 1 of 25 residents in the survey sample, Resident #76. The findings included: For Resident #76, the facility staff failed to follow the physician's order for a Modified Barium Swallow, a procedure to assess swallowing. Resident #76's diagnosis list indicated diagnoses, which included, but not limited to Schizoaffective Disorder Bipolar Type, Chronic Obstructive Pulmonary Disease Unspecified, Chronic Viral Hepatitis C, and Dysphagia following Unspecified Cerebrovascular Disease. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 8/30/21 assigned the resident a BIMS (brief interview for mental status score) of 13 out of 15 in section C, Cognitive Patterns. In section K, Swallowing/Nutritional Status, Resident #76 was coded as receiving 51% or more total calories received through parenteral or tube feeding and 501 cc/day or more of average fluid intake per day by IV or tube feeding while a resident of the facility and within the entire…

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.