Emporia Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, and clinical record review, the facility failed to provide care and services to ensure one Resident (Resident # 4) in a survey sample of 8 residents received care and services for Activities of Daily Living. (ADLs). Findings included: For Resident # 4, the facility staff failed to provide care and services for ADLs. Staff failed to document the provision of care for activities of daily living (ADLs) care on numerous dates and times. Resident # 4 was a [AGE] year-old with diagnoses including but not limited to: Dementia, Diabetes Mellitus-type 2, Chronic Kidney Disease Stage 3, Hypertension and history of a stroke in 2017. The admission MDS (Minimum Data Set) assessment tool with an ARD (Assessment Review Date) of 7/22/2023, coded Resident # 4 with a BIMS (Brief Interview for Mental Status) score of 00 out of 15, indicating severe cognitive impairment. It coded Resident # 4 as requiring extensive assistance of one staff person for ADLs (Activities of Daily Living) including toileting,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure one Resident (Resident # 4) in a survey sample of 8 residents, received care and services to prevent and identify an infected pressure ulcer. Findings included: For Resident # 4, the facility staff failed to prevent and identify a Stage 2 pressure ulcer (1) that was found when emergently discharged to the hospital on 8/28/2023. The pressure ulcer was cultured at the hospital and revealed a Pseudomonas Aeruginosa infection, resulting in harm. Resident # 4 was admitted on [DATE] with diagnoses including but not limited to: Dementia, Diabetes Mellitus-type 2, Chronic Kidney Disease Stage 3, Hypertension and history of a stroke in 2017. The admission MDS (Minimum Data Set) assessment tool with an ARD (Assessment Review Date) of 7/22/2023, coded Resident # 4 with a BIMS (Brief Interview for Mental Status) score of 00 out of 15, indicating severe cognitive impairment. It coded Resident # 4 as…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation, the facility staff failed to provide appropriate treatment and services for Residents who display or are diagnosed with mental disorder or psychosocial adjustment difficulty for one Resident (Resident #4) in a survey sample of 8 Residents. The findings included: For Resident #4 the facility staff failed to ensure that the Resident was seen by psychiatric (psych) services in order to provide a continuity of care after being discharged from the hospital where he was receiving psych services. Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia to Alzheimer's Disease and Vascular Dementia, with psychotic disturbance. He has a history of Agitation and sexual behavior disturbance. His BIMS score of 00/15 indicates severe cognitive impairment. Prior to admission to this facility, he was followed by Psych while a patient at the Veterans Hospital. Excerpts from Resident #4's discharge…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility documentation, the facility staff failed to provide appropriate treatment and services for Residents who display or are diagnosed with dementia for one Resident (Resident #4) in a survey sample of 8 Residents. The findings included. For Resident # 4 the facility staff failed to consult with a psychiatrist (psych) adding several psychotropic medications to his medication regimen. Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia to Alzheimer's Disease and Vascular Dementia, with psychotic disturbance. He has a history of Agitation and sexual behavior disturbance. His BIMS score of 00/15 indicates severe cognitive impairment. Prior to admission to this facility, he was followed by Psych while a patient at the Veterans Hospital. Excerpts from Resident #4's discharge summary from the (Name of Hospital) are as follows: Key Findings: We consulted psychiatry and adjusted your medications to help…

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

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure medications were available for administration for two Residents (Residents # 6 and # 3 ) in a survey sample of 8 residents. Findings included: 1. For Resident # 6, the facility failed to ensure medications were available for administration several times as ordered by the physician. Review of the clinical record was conducted 10/11/2023-10/13/2023. Review of the Progress Notes revealed the following documentation regarding medications being unavailable: Torsemide Oral Tablet 60 MG (milligrams) (Torsemide) Give 1 tablet by mouth one time a day for Edema -Order Date-08/25/2023 1640. The medication was unavailable 9/1/23, 9/5/23 and 9/6/23. Effective Date: 08/30/2023 20:03 Type: EMAR(Electronic Medication Administration Record) - Administration Note Text : Gabapentin Capsule 100 MG (milligrams) Give 1 capsule by mouth three times a day for Neuropathy awaiting medication. Review of the August 2023 and September 2023 Medical Administration Records revealed several…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation, the facility staff failed to ensure that a Resident was free from unnecessary medications to include duplicate drug therapy for one Resident (Resident #4) in a survey sample of 8 Residents. The findings included: For Resident #4 the facility staff failed to ensure the Resident was free from duplicate drug therapy to include 2 SSRI's (Selective Serotonin Reuptake Inhibitors), Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia to Alzheimer's Disease and Vascular Dementia, with psychotic disturbance. He has a history of Agitation and sexual behavior disturbance. His BIMS score of 00/15 indicates severe cognitive impairment. Prior to admission to this facility, he was followed by a psychiatrist (psych) while a patient at the (Name of) Hospital. Excerpts from Resident #4's discharge summary from the hospital are as follows: Key Findings: We consulted psychiatry and adjusted your…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, clinical record review and facility documentation the facility staff failed to ensure Resident was free from unnecessary psychotropic drug use for one Resident (Resident #4) in a survey sample of 8 Residents. The findings included: For Resident #4 the facility staff failed to prevent duplication of drugs, and failed to ensure PRN (as needed) anti-psychotic medication were limited to 14 days. Resident #4 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia to Alzheimer's Disease and Vascular Dementia, with psychotic disturbance. He has a history of Agitation and sexual behavior disturbance. Excerpts from Resident #4's discharge summary from the hospital are as follows: Key Findings: We consulted psychiatry and adjusted your medications to help alleviate some behavioral symptoms of dementia. You will be discharged to a long-term care center to better help your needs. Discharge summary from the hospital included the following psychotropic…

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 record review, the facility staff failed to have a sufficient surety bond to assure the security of all personal funds of residents deposited with the facility, affecting 85 of 93 facility Residents who had a patient trust account. The findings included: For 85 Residents, the facility staff failed to maintain a surety bond in a sufficient amount to assure the security of all personal funds deposited with the facility. On [DATE], during an entrance conference conducted with the facility Administrator, the survey team requested a copy of the facility surety bond and current Resident trust fund balance. On [DATE], the surety bond was reviewed and revealed that the coverage amount was for $125,000, but the bond expired/ended on [DATE]. The current Resident trust account balance was reviewed and revealed 85 Residents had open and active accounts with the facility. Of the 85 open accounts, 74 had an active balance, which totaled $126,453.02. On [DATE] at 8:56 AM, Surveyor B…

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

Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy for 14 employees (Staff #3, 8, 11, 12, 16, 19, 21, 22, 24, 25, 32, 33, 34 and 35) in a sample of 25 employees reviewed. The findings included: The facility staff failed to implement their abuse policy with regards to the pre-hire screening of 14 employees, including license/certification verifications and/or criminal background checks. On 11/13/22, during the entrance conference conducted with the facility Administrator, a listing of employees hired since the facility's previous licensure survey was conducted in 2019 was requested. On 11/14/22, the list of new hires was reviewed and a sample was selected. The facility Administrator was asked to provide evidence of the 25 sampled staff's sworn statement, criminal background check and professional license verification conducted prior to or at the time of hire. On 11/15/22 at 10:30 AM, the Administrator was asked to explain why criminal background checks (CBCs) are performed for potential employees. The Administrator…

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 facility documentation review, the facility staff failed to remove expired medications and supplies from the supply that was available for administration to residents in 1 of 3 medication carts, and in 2 of 3 medication storage rooms inspected. The findings included: 1. The facility staff failed to remove multiple expired medications from the supply available to residents on 1 medication cart on the East Wing. On 11/14/22 at 09:51 AM, an inspection of the East A medication cart was conducted by Surveyor B, in the presence of LPN F. The cart contained the following medications: a. Sodium Bicarbonate 10 gr (grams) (650 mg [milligrams]) antacid, bottle of 1000 white tablets, which was opened and 1/2 full, which expired October 2022. b. A 1000 count bottle of Acetaminophen Regular strength pain reliever 325 mg, which was open and 1/2 full, expired October 2022. LPN F confirmed the medications were expired and, despite this, were available for administration. When asked why it is important to ensure medications are not expired, LPN F said, We…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to follow proper sanitation protocol to prevent a potential outbreak of foodborne illness for 5 out of 12 days in November 2022. The findings included: The facility staff failed to verify acceptable chemical sanitation level in the sanitation sink for all three meals on 11/04/2022, 11/07/2022, and 11/12/2022; and following the dinner meal on 11/05/2022, 11/06/2022, 11/08/2022, 11/10/2022, and 11/11/2022. On 11/13/2022 at 12:25 P.M. this surveyor observed the 3-compartment sink log. All three meals on 11/04/2022, 11/07/2022, and 11/12/2022, and the dinner meals on 11/05/2022, 11/06/2022, 11/08/2022, 11/10/2022, and 11/11/2022 were blank. There was no evidence the chemical sanitation level was checked to ensure adequate sanitation of pans. On 11/13/2022 at 4:00 P.M., the administrator and Director of Nursing were notified of findings. On 11/14/2022 at 9:50 A.M., the dietary manager was interviewed. When asked about the expectation for the sanitation log, the dietary manager stated the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to implement effective infection control practices for one out of one building, and in one of three care units. The findings include: 1. The facility staff failed to maintain an effective water management program to prevent the growth of legionella. Legionella was confirmed in 5 of the 20 sources tested in July 2022. Also, the facility staff failed to treat the sources as recommended by the state certified biological water testing center, and check the effectiveness of the treatment they implemented on 08/05/2022. 1. On 11/15/2022 at approximately 3:45 P.M., the water management program was reviewed with the administrator. When asked how their building water systems were assessed for potential legionella pathogens, the administrator stated that testing samples were sent out. When asked about the testing results, the Administrator provided a copy of the testing results dated 08/02/2022. According to the legend of…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements during a facility wide COVID-19 Outbreak for facility staff and residents; and the facility staff failed to conduct COVID-19 testing for 2 residents, Residents #85 and #93, out of 2 newly admitted residents reviewed for COVID testing. The findings included: 1. The facility staff failed to conduct COVID-19 testing on October 29, 2022 following the identification of a COVID-19 Outbreak on October 27, 2022. On 11/15/22, a group interview was conducted with the Director of Nursing (DON) and the Infection Preventionist (IP). The DON stated the IP reported a resident had tested positive for COVID-19 on 10/26/22, and COVID-19 Outbreak broad-based testing began on 10/27/22 for all staff members and residents. The IP stated that the facility's…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to convey a resident's personal funds within 30 days of discharge to one resident, (Resident #303), in a survey sample of 37 Residents. The findings included: For Resident #303, the facility staff did not issue a refund of trust funds within 30 days of the Resident's discharge. On [DATE], a review of the Resident trust account Trial Balance report revealed that Resident #303 had a negative account balance in the amount of -$917.41. Review of the electronic health record revealed that Resident #303 was initially admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #303 expired at the hospital. On [DATE] at 8:56 AM, Surveyor B conducted an interview with the Business Office Manager/Employee M. Employee M was asked about Resident #303's negative account balance. Employee M said, It is money that is due back to his account, they deducted his care cost twice. I've sent them…

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

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to notify the responsible party for a change in condition for one Resident (Resident #80) in a sample size of 37 Residents. The findings included: For Resident #80, the facility staff failed to notify the responsible party when a new wound was discovered on 08/04/2022. On 11/14/2022 and 11/15/2022, Resident #80's clinical record was reviewed. An excerpt of a provider note dated 08/04/2022 at 8:41 A.M. under the header Assessment/Plan documented, Open wound to right sacral area-acute; new rec' [sic] given. The nursing progress notes from 08/04/2022 through 08/10/2022 were reviewed. There was no evidence the responsible party was notified. On 11/16/2022 at approximately 1:45 P.M., the Administrator and Director of Nursing (DON) were notified of findings. When asked about the expectation for responsible party notification of a new sacral wound, the DON stated the responsible party should have been notified. A review of the facility policy, Change in a Resident's Condition or…

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

Based on observation, Resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a homelike environment for one Resident (Resident #11) in a sample size of 37 Residents. The findings included: For Resident #11, the facility staff failed to ensure comfortable water temperatures for personal hygiene and incontinence care. On 11/13/2022 at 1:15 P.M., Resident #11 was interviewed. When asked about any care concerns, Resident #11 indicated that water in the bathroom sink does not get hot. Resident #11 stated that staff knows about it and they use cold cloths with incontinence care. During the course of the interview, this surveyor ran the hot water in the sink for approximately 3 minutes. The water did not heat up and felt cooler than 98.6 degrees Fahrenheit. On Resident #11's quarterly Minimum Data Set with an Assessment Reference Date of 08/17/2022, the Brief Interview for Mental Status was coded as 15 out of 15, indicating the resident was cognitively intact. A review Resident #11's care plan with a revision…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure that Residents are free from abuse and exploitation for 1 Resident (Resident #303) in a survey sample of 37 Residents. The findings included: For Resident #303, the facility staff misappropriated the Resident's money by deducting funds from the Resident's trust account after the Resident's discharge, leaving the account in a negative balance, and preventing the facility staff from issuing a refund due to the Resident for over a year following the Residents discharge. Review of the electronic health record revealed that Resident #303 was initially admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Resident #303 expired at the hospital. On [DATE], a review of the Resident trust account Trial Balance report revealed that Resident #303 had a negative account balance in the amount of -$917.41. On [DATE] at 8:56 AM, Surveyor B conducted an interview with the Business Office…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to permit a resident to return to the facility for one Resident (Resident #300) in a survey sample of 37 Residents. The findings included: For Resident #300, the facility staff failed to permit the Resident to be readmitted to the facility after being discharged to the hospital on [DATE]. Resident #300's diagnoses included, but were not limited to: Paranoid schizophrenia, major depressive disorder, bipolar disorder, and current episode manic severe with psychotic features. On [DATE], a clinical record review was conducted. This review revealed that Resident #300 was admitted to the facility on [DATE], and discharged on [DATE]. The Resident was then readmitted on [DATE], and discharged on [DATE]. According to the nursing notes, Resident #300 was sent to the hospital on [DATE] for increased lethargy, slurred speech, and decreased oxygen saturation. Review of Resident #300's progress notes revealed entries…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards of practice for 2 Residents (Resident #80, Resident #299) in a sample size of 37 Residents. The findings include: 1. For Resident #80, the facility staff failed to document assessment findings for a pressure ulcer. On 11/14/2022 and 11/15/2022, Resident #80's clinical record was reviewed. An excerpt of a provider note dated 08/04/2022 at 8:41 A.M documented, Open wound to right sacral area-acute; new rec' [sic] given. A weekly nursing skin assessment, Weekly Skin Review, dated 08/04/2022 at 1:10 P.M. documented that Resident #80's skin was intact. The nursing progress notes from 08/04/2022 through 08/10/2022 were reviewed. There was no evidence the newly discovered sacral wound was assessed, described, or measured. On 11/16/2022 at approximately 8:15 A.M., the Wound Nurse Practitioner (Employee P) and the Assistant Director 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 staff interview, facility document review, and clinical record review, the facility staff failed to complete a discharge summary to include recapitulation of stay for 1 resident (Resident #99) in the survey sample of 37 residents. The findings included: For Resident #99, the facility staff failed to complete a recapitulation (discharge summary) of care, after discharge from the facility on 8/9/22. Resident #99 was first admitted to the facility on [DATE], and discharged on 8-9-22. Resident #99's clinical record was reviewed and revealed a discharge minimum data set assessment (MDS), with an assessment reference date (ARD) of 8-9-22. Resident #99 was discharged to the hospital on 8-9-22. The Resident's closed record was reviewed on 11-15-22. Neither a discharge summary, nor a recapitulation of stay was included in the clinical record. The Administrator and Director of Nursing (DON) were notified of the missing discharge summary at the end of day meeting on 11-15-22. On 11-16-22 at 10:30 a.m. 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, facility document review, and in the course of a complaint investigation, the facility staff failed to provide adequate nutrition and hydration for one Resident (Resident #99) in a survey sample of 37 residents. The findings included: For Resident #99 the facility staff knew for 2 days that the Resident was not eating nor drinking sufficient fluids. Staff did not intervene, and the Resident was subsequently hospitalized with dehydration, malnutrition, bowel impaction, and severe Hypernatremia (high sodium in the bloodstream). Resident #99 was first admitted to the facility on [DATE], and discharged on 8-9-22. Resident #99's clinical record was reviewed and revealed a discharge minimum data set assessment (MDS) with an assessment reference date (ARD) of 8-9-22. The document coded the Resident with severe cognitive impairment, unable to walk, unable to feed self, and extensive to total dependence on staff for all activities of daily living. Resident #99 was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide influenza vaccines for 3 residents, Residents #5, #8, and #34, out of 5 residents reviewed for influenza immunization; and facility staff failed to provide a pneumococcal vaccine for 1residents, Resident #8, out of 5 residents reviewed for pneumococcal immunization. The findings include: 1. The facility staff failed to provide influenza immunization for Residents #5, #8, #34, and #77. 1a. Resident #5, who was admitted to the facility on [DATE], had no clinical assessment with regard to current influenza immunization status, no evidence of being offered immunization against influenza, and no documentation of resident refusal or medical contraindication. On 11/14/22, an interview was conducted with the Director of Nursing (DON), who accessed the clinical record for Resident #5 and verified the findings. A review of the facility policy, Vaccination of Residents, dated October 2019 revealed, in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff record review, staff interview, and facility documentation review, the facility staff failed to provide COVID-19 immunization for 1 resident, Resident #77, in a survey sample of 5 residents reviewed for COVID-19 vaccination. The findings include: The facility staff failed to offer and/or provide a second primary COVID-19 vaccine to Resident #77. Resident #77, was admitted to the facility on [DATE]. A review of the clinical record revealed a COVID-19 Vaccination Screening & Encounter Form, which documented the consent and administration of COVID-19 Vaccine Moderna (0.5ml), 1st dose on 9/13/21. Resident #77 had no documentation with regard to an offer to provide a second primary dose of the Moderna COVID-19 vaccine, education, or documentation of resident refusal or medical contraindication. On 11/14/22, an interview was conducted with the Director of Nursing (DON), who verified the findings for Resident #77. The DON stated a second COVID-19 vaccine should have been offered to Resident #77 in order…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to provide quality of care for three Residents (Resident #53, Resident #81, and Resident #41) in a survey sample of 35 Residents. 1. For Resident #53, the facility staff failed to assess the resident to determine the cause of her distress (i.e. crying), and seek appropriate treatment. The resident was documented as crying for 9 of 16 days. 2. For Resident #81, the facility staff failed to identify, assess, treat and monitor a skin wound on his left upper forearm. 3a. For Resident #41, the facility staff failed to document the administration of multiple medications during April, 2019. 3b. For Resident #41, the facility staff failed to administer five doses of physician-ordered insulin in April, 2019. The findings included: 1. For Resident #53, the facility staff failed to assess the resident to determine the cause of her distress (i.e. crying), and seek appropriate…

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

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food in accordance with professional standards for food service safety. 1. Facility staff failed to provide a sanitizing solution with appropriate concentration levels to ensure adequate sanitization during manual dishwashing. 2. Facility staff failed to properly label and date food items stored in the walk-in freezer. 3. Facility staff failed to follow appropriate hygiene/sanitary procedures by not wearing a hairnet in the kitchen. The Findings included: 1. Facility staff failed to provide a sanitizing solution with appropriate concentration levels to ensure adequate sanitization during manual dishwashing. On 04/16/2019 at approximately 08:00 AM, a tour of the kitchen took place and a three part sink was observed with the right compartment approximately 2/3 full with clear water which the Dietary Assistant (Other Employee A) described as the sanitizing solution. She stated that the solution was prepared using chlorine bleach just a few minutes earlier in…

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

Based on staff interview, facility documentation review, facility staff failed to complete an Advanced Beneficiary Notice (ABN) for one (Residents # 60) of 3 sampled residents. 1. For Resident # 60, the facility staff did not complete an Advanced Beneficiary Notice (ABN) timely. The findings included: 1. For Resident # 60, the facility staff did not complete an Advanced Beneficiary Notice (ABN) timely. Resident # 60 was chosen from a list of residents discharged in the previous 6 months. On 4/17/2019 at 9:00 AM, the Business Office Manager was asked for a copy of the Advance Beneficiary Notice for Resident # 60. The Business Office Manager presented a form that she stated was the ABN. The reviewed form showed Form CMS-10123 NOMNC (Notice of Medicare Non-Coverage) form was not signed by the resident or the authorized representative. The form had information documented in the additional information section that stated Your record shows the services you need no longer meet Medicare guidelines to be given in a skilled nursing facility (SNF). The guidelines require that you need daily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to provide a clean environment for one resident (Resident #81) in a sample size of 35 residents. The bathroom in Resident #81's room had mold on the floor, had a strong odor of mold and urine, and the hot water handle on Resident #81's room sink was loose. The findings included: Resident #81, an [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia without behavioral disturbance, hypertension, and dysphasia. Resident #81's most recent Minimum Data Set with an Assessment Reference Date of 03/19/2019 was coded as a quarterly review. Cognitive skills for daily decision-making was coded as severely impaired. Toileting and personal hygiene were coded as total dependence on staff. On 04/16/2019 at approximately 9:55 AM, a survey of Resident #81's room was conducted. Upon opening the bathroom door, there was a strong odor of mold and urine detected. There was urine in…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility documentation review, the facility staff failed for one resident (Resident #72), in the survey sample of 35 residents, to notify the Ombudsman of a hospital transfer. The facility staff failed to notify the Ombudsman that Resident #72 had been transferred to the hospital. The Findings included: Resident #72 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #72's diagnoses included Type 2 Diabetes Mellitus, Congestive Heart Failure, Rheumatoid Arthritis and Hemiplegia. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 3/22/19 was reviewed. It coded Resident #72 as having a Brief Interview of Mental Status Score of 15, indicating that there was no cognitive impairment. On 4/17/19 a review was conducted of Resident #72's clinical record. The Nurse's note read, 4/5/19. 11:25 (AM). Resident was sent to ER (Emergency Room) on previous day for evaluation of rash spreading on left upper leg.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation and clinical record review the facility failed to ensure that a Level II PASARR (Pre admission Screening And Resident Review) was performed prior to admission for 1 Resident (# 45) in a survey sample of 35 Residents. For Resident #45, the facility staff failed to obtain a PASARR prior to admission. The findings included; Resident #45 an [AGE] year old man admitted to the facility on [DATE] with diagnosis of but not limited to unspecified psychosis not due to a substance or known physiological condition, altered mental status, Major depressive disorder, Psychotic and behavioral factors associated with disorder classified elsewhere, Parkinsonism, and Osteoarthritis. On 4/17/19 during clinical record review it was noted that Resident #45 had a PASARR Level One that stated: 1. Does the individual meet nursing facility criteria? YES 2. Does the individual have a current serious mental illness (MD)? YES a. Is this major mental disorder diagnosable under DSM IV (e.g.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, clinical record review, and facility documentation, the facility staff failed to develop comprehensive, resident-centered care plan for 2 residents (Resident #14, Resident #81) in a sample size of 35 residents. 1. For Resident #14, the facility staff failed to develop and implement an Activities program. 2. For Resident #81, the facility staff failed to develop a plan of care for a skin wound on his left upper forearm. The findings included: 1. For Resident #14, the facility staff failed to develop and implement an Activities program. Resident #14, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to unspecified dementia without behavioral disturbance and gastroesophageal reflux disease. Resident #14's most recent Minimum Data Set with an Assessment Reference Date of 01/15/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 7 out of a possible 15 indicative of severe…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review the facility staff failed to review and revise the careplan for three residents (Resident #22, Resident #43, and Resident #81) in a survey sample of 35 residents. 1. For Resident #22, the facility staff failed to review and revise the careplan to include the physician ordered, pureed diet with nectar thick liquids. 2. For Resident #43, the facility staff failed to review and revise the careplan to include the physician ordered palm guards. 3 For Resident #81, the facility staff failed to revise the care plan on the status of an anti-anxiety medication. The findings included: 1. For Resident #22, the facility staff failed to review and revise the careplan to include the physician ordered, pureed diet with nectar thick liquids. Resident #22, was originally admitted to the facility on [DATE], with a most recent readmission on [DATE]. Diagnoses for Resident #22 included but were not limited to: unspecified psychosis, unspecified…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, clinical record review, and facility documentation, the facility staff failed to plan and implement Activities for one resident (Resident #14) out of a sample size of 35 residents. The findings included: Resident #14, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to unspecified dementia without behavioral disturbance and gastroesophageal reflux disease. Resident #14's most recent Minimum Data Set with an Assessment Reference Date of 01/15/2019 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 7 out of a possible 15 indicative of severe cognitive impairment. Toileting, dressing, and personal hygiene were coded as total dependence on staff. On 04/16/2019 at approximately 8:40 AM, Resident #14 was observed sleeping in his bed with the head of the bed elevated approximately 45 degrees. Resident #14 was wearing a white, short-sleeved t-shirt and covered with a blanket from the waist down. On…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and clinical record review the facility staff failed to provide services to prevent the development of pressure ulcers for one resident (Resident #22) in a survey sample of 35 Residents. For Resident #22, the facility staff failed to provide prevalon boot to left foot, as ordered by the physician, to prevent the development of a pressure ulcer. The findings included: Resident #22, was originally admitted to the facility on [DATE], with a most recent readmission on [DATE]. Diagnoses for Resident #22 included but were not limited to: unspecified psychosis, unspecified intellectual disabilities, difficulty in walking, type 2 diabetes, gastro-esophageal reflux disease, hypertension, anxiety, and unspecified convulsions. Resident #22's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/23/19, was coded as a significant change assessment. Resident #22 was coded as having a BIMS (brief interview for mental status) score of 6, which…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and clinical record review the facility staff failed to provide services to prevent the decline in ROM (range of motion) for one resident (Resident #43) in a survey sample of 35 Residents. For Resident #43, the facility staff failed to provide palm guards, as ordered by the physician, to prevent the decline in ROM. The findings included: Resident #43, was originally admitted to the facility on [DATE], with a most recent readmission on [DATE]. Diagnoses for Resident #43 included but were not limited to: age related osteoporosis, glaucoma, dementia, pick's disease and unspecified kidney failure. Resident #43's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 2/22/19 was coded as a quarterly assessment. Resident #43 was coded as having severe cognitive impairment based on a staff assessment, a BIMS (brief interview for mental status) was not able to be conducted. Resident #43 was coded as being total care, dependent upon one staff member, for…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards on one of three nursing units. The facility staff failed to lock and secure a housekeeping cart on the 200 hall, which included chemicals and a sharp object. The findings included: During facility rounds on 4/17/19 at 9:23am a housekeeping cart was observed, unattended outside of room [ROOM NUMBER]. Residents, visitors, and staff were observed in the hallway that could access the contents of the housekeeping cart. The cabinet door, where chemicals and sharp objects were stored, was observed to be ajar. When opened, the following contents were observed: 1. Enzym D- a cleaning chemical 2. a roll of trash bags 3. a pair of scissors with a sharp, pointed end 4. a toilet bowl brush 5. a scrapper (rectangle shaped metal (approximately 3 long, 2 wide), with a plastic handle) 6. hand sanitizer On 4/17/19 at 9:25am an interview was conducted with a housekeeper, other…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility documentation, and hospital discharge record review the facility staff failed to ensure Residents free from unnecessary medications for 1 Resident (#77) in a survey sample of 35 Residents. For Resident #77 the facility staff failed to hold or discontinue Colace 100 (Milligrams) mg twice daily [given for constipation] when the Resident had loose stools since readmission from the hospital. The findings included; Resident #77 an [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to left and right above knee amputation, Hemiplegia following cerebral infarction (stroke), Contracture multiple sites, Pressure ulcer (unstageable), Diabetes type 2, and chronic Atrial fibrillation and history of pacemaker. Resident #77's most recent (Minimum Data Set) MDS coded as a PPS 60 Day Scheduled Assessment, codes Resident as having a (Brief Interview of Mental Status) BIMS Score of 0. A score of 0 indicates the Resident has…

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 representative interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide dental services for one resident (Resident #53) in a survey sample of 35 residents. The facility staff failed to provide routine dental services for Resident #53. The findings included: Resident # 53 had an original admission on [DATE], with a recent readmission on [DATE]. Resident #53's diagnoses included but were not limited to: Parkinson's, dysphagia, hyperglycemia, hypokalemia, vascular dementia, GERD, and C4 Cervical Spinal Cord Injury. Resident #53's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/6/19, was coded as a quarterly assessment. Resident #53 was coded as being severely cognitively impaired. For activities of daily living (ADL's) to include transfers, dressing, eating, personal hygiene, toileting and bathing, Resident #53 was totally dependent on one staff member for care. On 4/16/19 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to provide a therapeutic diet, as ordered by the physician, for one resident (Resident #22) in a survey sample of 35 Residents. For Resident #22, the facility staff failed to nectar thick liquids as ordered by the physician. The findings included: Resident #22, was originally admitted to the facility on [DATE], with a most recent readmission on [DATE]. Diagnoses for Resident #22 included but were not limited to: unspecified psychosis, unspecified intellectual disabilities, difficulty in walking, type 2 diabetes, gastro-esophageal reflux disease, hypertension, anxiety, and unspecified convulsions. Resident #22's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/23/19, was coded as a significant change assessment. Resident #22 was coded as having a BIMS (brief interview for mental status) score of 6, which indicated severe cognitive…

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 an accurate medical record for 2 residents (Resident #22 and Resident #43) in a survey sample of 35 Residents. 1. For Resident #22 the facility staff failed to conduct a quarterly review of Resident #22, to determine that placement in a secure unit continued to be appropriate for the resident. 2. For Resident #43 the facility staff failed to conduct a quarterly review of Resident #43 to determine that placement in a secure unit continued to be appropriate for the resident. The findings included: 1. For Resident #22 the facility staff failed to conduct a quarterly review to determine that continued placement in a secure unit was appropriate. Resident #22, was originally admitted to the facility on [DATE], with a most recent readmission on [DATE]. Diagnoses for Resident #22 included but were not limited to: unspecified psychosis, unspecified intellectual disabilities, difficulty in walking, type 2 diabetes, gastro-esophageal…

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

Based on staff interview, and facility documentation review, the facility staff failed to maintain a Quality Assessment and Assurance (QAA) Committee consisting of the minimum members in two of four quarters from April 2018- March 2019. 1. For the April 24, 2018 Quarterly QAA meeting, the administrator was not in attendance and the Administrator and Director of Nursing did not attend the January 28, 2019 Quarterly QAA meeting. The findings included: 1. For the April 24, 2018 Quarterly QAA meeting, the administrator was not in attendance and the Administrator and Director of Nursing did not attend the January 28, 2019 Quarterly QAA meeting. On 4/19/2019 at 11:10 AM, an interview was conducted with the Director of Nursing and Risk Manager who both stated the facility held quarterly meetings as scheduled as well as monthly meetings to discuss quality assurance. The Director of Nursing stated she and the administrator attended the QAA meetings each quarter as scheduled. On 4/18/19 at 11:15 AM, a review of the facility's Quality Assessment and Assurance (QAA) committee was conducted with…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident interview, facility documentation review, and clinical record review, the facility staff failed to ensure infection prevention for 1 Resident (Resident #36) in a survey sample of 35 Residents. For Resident #36, the facility staff failed to ensure a partially full urinal was not present by his plate of food during meal services. The findings included; Resident # 36 a [AGE] year old man admitted to the facility on [DATE] with diagnosis of but not limited to Congestive Heart Failure, Hypertension, Renal Failure, and Schizophrenia. Resident #75's last (Minimum Data Set) MDS (screening tool) coded Resident as having a (Brief Interview of Mental Status) BIMS score of 15 indicating no cognitive impairment. The Resident is also coded as being incontinent and using a urinal at bedside. On 4/16/19 at 8:00 AM during initial tour, Resident #36 was sitting on the side of bed with bed table in front of him eating breakfast. Directly to the right of his plate was a urinal half…

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 representative interview, and staff interview the facility staff failed to maintain equipment in safe operating condition for one resident (Resident #53) in a survey sample of 35 residents. The facility staff failed to maintain the bed and room in safe repair for Resident #53. The findings included: Resident # 53 had an original admission on [DATE], with a recent readmission on [DATE]. Resident #53's diagnoses included but were not limited to: Parkinson's, dysphagia, hyperglycemia, hypokalemia, vascular dementia, GERD, and C4 Cervical Spinal Cord Injury. Resident #53's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/6/19, was coded as a quarterly assessment. Resident #53 was coded as being severely cognitively impaired. For activities of daily living (ADL's) to include transfers, dressing, eating, personal hygiene, toileting and bathing, Resident #53 was totally dependent on one staff member for care. On 4/16/19 at 02:41 PM,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. For Resident # 64 the facility failed to document medications as having been administered. Resident #64, a [AGE] year old, was admitted to the facility on [DATE]. His diagnoses included diabetes, chronic kidney disease, pressure ulcer, and hypertension. The most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 12/19/17. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required extensive assistance with activities of daily living. Resident #64's January 2018 Medication Administration Record (MAR) was reviewed. On the 3-11 shift, there were multiple instances where the nurse failed to document the administration of medications. Medications were not documented as having been administered on the following occasions: Docusate 9:00 p.m.: 1/4/18, 1/15/18, 1/17/18 and 1/22/18 Acetaminophen 8:00 p.m.: : 1/4/18, 1/15/-1/17/18, 1/22/18 Alfuzosin 8:00 p.m.: 1/4/18, 1/15/, 1/17/18, 1/22/18 Atorvastatin 8:00 p.m. : 1/4/18,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to provide activities for six residents (Residents # 65, 47, 46, 83, 10 and 60) in a survey sample of 21 residents. 1. For Resident # 65, the facility staff failed to provide Activities to residents during survey 1/24/2018 through 1/26/2018. 2. For Resident # 47, the facility staff failed to provide Activities during 3 days of survey 1/24-1/26/2018. 3. For Resident # 46, the facility staff failed to provide Activities during 3 days of survey 1/24-1/26/2018. 4. For Resident # 83, the facility staff failed to provide Activities during 3 days of survey 1/24-1/26/2018. 5. No meaningful activities were assessed for, nor planned for Resident #10. 6. No meaningful activities were assessed for, nor planned for Resident #60. Findings included: During the first 3 days of survey on January 24, 25 and 26, 2018, there were no Activities observed being conducted in the facility. On 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review the facility staff failed for 1 resident (Resident #64) of 21 residents in the survey sample to ensure pharmacy recommendations were acted upon. For Resident #64, the pharmacist recommended that the facility obtain a digoxin level nine times before the level was obtained. The findings included: Resident #64, a [AGE] year old, was admitted to the facility on [DATE]. His diagnoses included diabetes, chronic kidney disease, pressure ulcer, and hypertension. The most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 12/19/17. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required extensive assistance with activities of daily living. The pharmacist completed the monthly Drug Regimen Review (DRR) form for Resident #64. The forms were filed in the resident record. In addition, the pharmacist provided the Director of Nursing (DON) with a print out of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure five Residents were free from significant medication error (Residents #10, 29, 40, 83, and 47) in a survey sample of 21 Residents. 1. For Resident #10, the facility failed to administer anti seizure medication as ordered by a physician. 2. For Resident #29, the facility failed to administer insulin as ordered by a physician. 3. For Resident #40, the facility failed to administer anti seizure medication as ordered by a physician. 4. For Resident # 83, the facility staff failed to document the administration of Insulin for Diabetic Management and Anti-seizure medications. 5. For Resident # 47, the facility staff failed to document the administration of anti-seizure medications as ordered by the physician. The findings included: 1. Resident #10, was admitted to the facility on [DATE]. Diagnoses included; left tibia fracture with surgical repair infection and revision of implanted device,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interview and clinical record review the facility staff failed for 1 resident (Resident #77) of 21 residents in the survey sample to ensure the resident had been assessed to self administer medications. Resident #77's medications were left at the bedside. She took the medications without supervision. The findings included: Resident #77, a [AGE] year old, was admitted to the facility on [DATE]. Her diagnoses included chronic pain, dysphagia, breast cancer, cerebrovscular disease, and anxiety. Her most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 1/3/18. She was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. She required limited assistance with activities of daily living. On 1/24/18 at 10:20 a.m., Resident #77 was in her room. She was heard coughing repeatedly. Upon entrance to the room, Resident #77 was seated in her wheel chair in front of the overbed table. On top…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to notify the responsible party of falls for 1 Resident (Resident #60) in a survey sample of 21 Residents. For Resident #60, the facility staff failed to notify the Responsible party of recurring falls. The findings included: Resident #60, was admitted to the facility on [DATE]. Diagnoses included; stroke, diabetes, drug and alcohol abuse, high blood pressure and high cholesterol. Resident #60's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12-15-17 was coded as a full admission assessment. Resident #60 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or cognitively intact. This was an error, as the Resident was not cognitively intact. Resident #60 was also coded as requiring extensive assistance of one staff member to perform activities of daily living, such as bed mobility, transferring, eating, locomotion, 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 clinical record review, the facility staff failed for 1 resident (Resident #65) of 21 residents in the survey sample to ensure personal privacy. For Resident #65, the facility staff failed to knock on the door, and or announce themselves prior to entering the bedroom. The Findings included: Resident #65 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #65's diagnoses included Major Depressive Disorder, Seizures, Hemiplegia, and Hypertension. The Minimum Data Set, which was a Annual Assessment with an Assessment Reference Date of 12/19/17, coded Resident #65 as having a Brief Interview of Mental Status Score of 1, indicating severely impaired cognition. On 1/24/18 at 9:00 A.M. an observation was conducted of the medication pass. Licensed Practical Nurse A was observed entering Resident #65's room in order to wash her hands. LPN A entered to the bedroom without knocking or announcing herself to either Resident #65 or his roommate. LPN A quickly…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Observation and Staff Interview, the facility staff failed to maintain a safe, clean, comfortable environment for one resident (Resident #21) in a sample of 21 residents. For Resident #21, the right arm of the wheel chair was torn and taped. The findings included: Resident #21 was admitted on [DATE]. Resident #21's diagnoses included: Hypothyroidism, unspecified dementia without behavioral disturbances, major depressive disorder, Parkinson's Disease, other chronic pain, essential hypertension, chronic atrial fibrillation, Gastro-Esophageal Reflux Disease with esophagitis, Bilateral Primary Osteoarthritis of the knees, difficulty walking, and lack of coordination. Resident #21's most recent Minimum Data Set (MDS) Assessment was a Quarterly Assessment with an ARD (Assessment Reference Date) of 11/09/17. The assessment coded Resident #21 with a BIMS (Brief Interview of Mental Status, an evaluation of cognitive status) score of 8, indicating Moderate Impairment. On 1/24/18, Resident #21 was observed in his…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and clinical record review, the facility staff failed to complete an accurate MDS (minimum data set) RAI (Resident Assessment Instrument) for two Residents (Resident #60 and Resident #66) in a survey sample of 21 Residents. For Resident #60, the facility staff failed to accurately code number of falls since admission (1900A), cognitive status (C0500) in the admission MDS, and Bowel and bladder Continence was also inaccurate from comparison between the care plan, MDS, and the CAA's. The findings included: Resident #60, was admitted to the facility on [DATE]. Diagnoses included; stroke, diabetes, drug and alcohol abuse, high blood pressure and high cholesterol. Resident #60's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12-15-17 was coded as a full admission assessment. Resident #60 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or cognitively intact. This was an error, as the Resident was not cognitively…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family interview, staff interview and clinical record review, the facility staff failed to provide a summary of the care and services for the Resident, to the Resident's Responsible party in a manner that was understandable to that individual. Also, the facility staff did not give updated interventions as they became available, for one Resident (Resident #60) in a survey sample of 21 Residents. For Resident #60, the facility staff failed to provide the Responsible party with a baseline care plan of services, and failed to provide the Responsible party with revisions of care plan interventions as they became available and necessary. The findings included: Resident #60, was admitted to the facility on [DATE]. Diagnoses included; stroke, diabetes, drug and alcohol abuse, high blood pressure and high cholesterol. Resident #60's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12-15-17 was coded as a full admission assessment. Resident #60 was coded as having a 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, the facility failed to develop a comprehensive care plan for two residents (Resident #60 and Resident #21) in a survey sample of 21 residents. 1. For Resident #60, the facility staff signed as having completed the comprehensive care plan, and failed to address all of the care areas triggered in the MDS assessment. 2. For Resident #21, the comprehensive care plan did not document that the resident suffered from chronic pain. The findings included: Resident #60, was admitted to the facility on [DATE]. Diagnoses included; stroke, diabetes, drug and alcohol abuse, high blood pressure and high cholesterol. Resident #60's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12-15-17 was coded as a full admission assessment. Resident #60 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or cognitively intact. This was an error, as the Resident was 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide diabetic management for one resident (Resident # 83) in a survey sample of 21 residents. For Resident # 83, the facility staff failed to obtain Finger Stick Blood Sugars (FSBS) and administer Insulin as ordered by the physician. Findings included: Resident #83 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included but were not limited to Vascular Dementia with behavioral disturbances, Diabetes and Complete Traumatic Amputation of left lower leg. The most recent Minimum Data Set (MDS) assessment was an admission Assessment with an Assessment Reference Date of 10/19/2018. The MDS coded Resident #83 as having a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment. Resident # 83 was also coded as requiring limited to total assistance of one staff member for Activities of Daily Living (ADLs). The only exception to this was eating, which…

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 interviews, and clinical record review, the facility staff failed to ensure that pain management was provided to two residents (Resident #21 and Resident #77) in a sample of 21 Residents. 1. For Resident #21, facility Staff failed to offer physician ordered topical cream and other, non-pharmacological, pain control interventions. 2. For Resident #77, the facility staff failed assess pain and failed to administer pain medication when the resident expressed that she was in pain. The Findings Included: 1. For Resident #21, facility Staff failed to offer physician ordered topical cream and other, non-pharmacological, pain control interventions. Resident #21's diagnoses included: Hypothyroidism, unspecified dementia without behavioral disturbances, major depressive disorder, Parkinson's Disease, other chronic pain, essential hypertension, chronic atrial fibrillation, Gastro-Esophageal Reflux Disease with esophagitis, Bilateral Primary Osteoarthritis of the knees, difficulty walking,…

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 for 1 resident (Resident #64) of 21 residents in the survey sample to ensure the resident was free from unnecessary medications. For Resident #64, Cardizem (blood pressure medication) was administered when it should have been held. The findings included: Resident #64, a [AGE] year old, was admitted to the facility on [DATE]. His diagnoses included diabetes, chronic kidney disease, pressure ulcer, and hypertension. The most recent Minimum Data Set assessment was an annual assessment with an assessment reference date of 12/19/17. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required extensive assistance with activities of daily living. Resident #64 had a physician order dated 12/14/17 for Cardizem 1 tab by mouth 3 times a day- check pulse before dosing, hold for pulse less than 60 and notify doctor. The January 2018 Medication Administration Record (MAR) was reviewed. On 1/3/18 at…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed to ensure the resident was free from un-necessary medications for two residents, (Resident #71 and Resident #15) in a survey sample of 21 residents. 1. Resident #71's Ativan PRN (as needed) antianxiety medication was administered without assessing the resident at the end of every 14 day continued use, and renewing the PRN order every 14 days. 2. For Resident #15, the facility staff failed to ensure the resident was free from unnecessary medications. The findings included: 1. Resident #71 was admitted to the facility on [DATE], and readmitted [DATE]. Diagnoses included; Alzheimer's Dementia, left hip fracture with repair and dementia with behavioral disturbance, psychosis, anxiety, osteoporosis, and gastro-esophageal reflux disease. Resident #71's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12-26-17 was coded as a quarterly assessment. Resident #71 was coded as having no 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.

Based on observation and staff interview the facility staff failed to store and serve food in accordance with professional standards for food service safety. A fan with dust caked on the back of the frame was found blowing air over the area where dishes were washed and racked to dry. The findings included: An initial tour of the Kitchen was conducted on 1/24/18 at 9:06 am. During tour, it was observed that several wall-mounted fans were in use circulating air throughout the kitchen. One fan overlooking the dishwashing and drying area was observed to have thick dust caked on the rear of the housing covering the blades, in the air intake area. Inspection of the ice machine in the kitchen revealed that there was no air gap between the drainage pipe and floor drain. The far end of the drain pipe coming from the rear of the ice machine was resting inside the lip of the floor drain. The issues with the Kitchen were reviewed with the Kitchen Manager on 1/29/18 at approximately 10:50. The manager stated that a work order would be placed to have the fan cleaned. No further information was…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and clinical record review, the facility staff failed, for two residents (Residents #10, and #60) to maintain a complete and accurate clinical record in the survey sample of 21 residents. 1. No meaningful activity records existed in the clinical record for Resident #10. 2. No meaningful activity records existed in the clinical record for Resident #60. The findings included: 1. Resident #10, was admitted to the facility on [DATE]. Diagnoses included; left tibia fracture with surgical repair infection and revision of implanted device, hypertension, seizures, contractures, and congestive heart failure. Resident #10's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-17-18 was coded as an admission assessment. Resident #10 was coded as having a BIMS (brief interview of mental status) score of 13 out of a possible 15, or, mild to no cognitive impairment. Resident #10 was also coded as requiring extensive to total assistance of staff to perform…

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, the facility staff failed for 1 resident (Resident #65) of 21 residents in the survey sample to practice appropriate hand washing prior to medication administration. And, the facility staff failed to have air gaps on the ice machines in the kitchen and on Unit 1. 1. For Resident #65, the facility staff failed to knock on the door, and or announce themselves prior to entering the bedroom. 2. The facility failed to have air gaps on the ice machines in the Kitchen and on Unit 1. The Findings included: Resident #65 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #65's diagnoses included Major Depressive Disorder, and Hypertension. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 11/4/17, coded Resident #65 as sometimes being able to understand and be understood by others. On 1/24/18 at 9:00 A.M. an observation was conducted of the medication pass. Licensed Practical Nurse A 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.