Greensville Health And Rehabilitation Center

Based on observation, staff interviews and clinical record review, the facility staff failed to ensure quality of care based on professional standards and the person-centered care plan was provided for one Resident (Resident #38) in a survey sample of 44 Residents. The findings included: For Resident #38 the facility staff failed to ensure that the Resident had appropriate seating to maintain her comfort, relieve pressure, prevent her legs from dangling, which would promote swelling/edema in her legs and feet; and be safe in the facility provided wheelchair. On 7/25/23, Resident #38 was observed sitting in a wheelchair at the nursing station. Resident #38 was observed to be sitting on two cushions, which elevated her to the point that her legs were dangling and not touching the floor. Footrests were not on the chair. Observations of Resident #38's room revealed leg rests and foot pedals for the wheelchair in the floor next to the bed. Also noted was a 1/2 tray that would go on the wheelchair but was not in use. On 7/26/23, a clinical record review was conducted. This review revealed…

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

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide/arrange for one Resident (Resident #13) in a survey sample of 44 Residents to obtain new prescription lenses in her glasses, as ordered. The findings included: On 7/25/23 at 2:40 PM, during initial tour, Resident #13 was visited in her room. Resident #13 was asked about her vision and the Resident said, I need to get my vision checked and reported she is having difficulty seeing. The Resident did not recall last time she saw eye doctor. On 7/26/23, a clinical record review was conducted of Resident #13's chart. This review revealed the following: Resident #13 had a physician order dated 9/15/22, that read, May have consultation for ophthalmology, podiatry, dental and optometry as needed. Resident #13's care plan was reviewed, and her vision or use of glasses was not identified on the care plan. Documentation regarding the offering of an eye exam with regards to the Resident's report of difficulty seeing was not found in the clinical chart. On 7/26/23, the…

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

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to implement interventions to prevent the development of pressure ulcers for one Resident (Resident #35) in a survey sample of 44 Residents. The findings included: For Resident #35, who was at risk for the development of a pressure ulcer, the facility staff failed to apply heel protective boots as ordered by the physician. A clinical record review was conducted and revealed that Resident #35 had a physician order dated 5/23/23, that read, place heel protector on right heel every shift for wound. An excerpt from Resident #35's care plan read, The resident has potential for pressure ulcer development r/t [related to] immobility, incontinent of B&B [bowel and bladder]. Interventions for this care plan focus area was, Administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown . Resident #35's most recent Braden Scale for Predicting Pressure Sore Risk was conducted 5/23/23, and the…

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

Based on observation, interview, record review, and facility policy review, the facility failed to provide splints to address range of motion loss and/or contractures for two of five residents (Resident (R)19, and R5) reviewed for limited range of motion. These failures had the potential to cause worsening contractures for these two residents. Findings include: Review of the facility policy titled Braces, Splints, and Prostheses, dated 04/20/11 revealed, Braces, splints, and prostheses assist a resident with support normal joint alignment and positioning. These devices also prevent or minimize deformities such as contractures. As a result, these devices facilitate mobility and activity of daily living skills. Braces, splints and prostheses may only be removed with orders of M.D. [medical doctor] 1. Review of R19's Medical Diagnosis, sheet located in the Med Diag [diagnosis] tab of the electronic medical record (EMR), revealed R19 had diagnoses which included hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, and lack 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.

Based on observation, interview, record review, and facility policy review the facility failed to administer enteral feedings as ordered for one of one sampled Resident (R)213 reviewed for enteral feedings. This failure had the potential to cause weight loss and/or other nutritional complications for this resident. Findings include: Review of the facility's policy titled, Enteral Nutrition, revised on 11/18, revealed, Adequate nutritional support through enteral nutrition is provided to residents as ordered. Review of R213's Medical Diagnosis, sheet located in the Med Diag [diagnosis] tab of the electronic medical record (EMR), revealed R213 had diagnoses which included dysphagia and severe protein-calorie malnutrition. Review of R213's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/23, located in MDS tab of the EMR, specified the resident had a feeding tube and received 51 percent or more of her total calories through the feeding tube. The resident had a Brief Interview for Mental Status (BIMS) score of 0/15, 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.

Based on observation, staff interview and facility documentation review, the facility staff failed to implement a system to assure the accurate accounting of controlled medications on 2 of 3 medication carts inspected and failed to ensure medications were available for use for 1 (Resident #55) of 44 sampled residents. The findings included: 1. The facility staff failed to ensure the correct quantity of controlled medications was accurate on 2 medication carts. On 07/26/23 at 09:11 AM, a medication cart on the East wing nursing station. The observation/inspection was conducted in the presence of LPN E. During a controlled medication count, it was noted that Resident #164's Clonazepam 1 mg tablet's corresponding controlled drug count sheet indicated 9 tablets should be present. Observation of the card revealed only 8 tablets. LPN E confirmed the findings. Observation of Resident #15's Lorazepam 0.5 mg revealed 3 tablets present and the controlled medication count sheet indicated 4 tablets should have been present. Resident #15's Tramadol HCL 50 mg tablet medication card was noted to…

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

Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to offer routine dental care for one Resident (Resident #13) in a survey sample of 44 Residents. The findings included: On 7/25/23, during initial tour, Resident #13 was visited in her room. Resident #13 was observed to have many teeth that were broken at the gum and were discolored, black in color. When asked, Resident #13 denied pain, but also stated she had not seen a dentist. When asked if this was something she would be interested in, Resident #13 indicated yes. On 7/26/23, a clinical record review was conducted of Resident #13's chart. This review revealed the following: Resident #13 had a physician order dated 9/15/22, that read, May have consultation for ophthalmology, podiatry, dental and optometry as needed. Resident #13 had a care plan that read, [Resident #13's name redacted] has oral/dental health problems r/t [related to] Poor oral hygiene. The associated interventions for this care plan read, . Coordinate arrangements for dental care, transportation 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 observation, staff interview, and electronic medical record (EMR) review, the facility failed to provide dental services for 4 of 8 residents (Resident (R) 6, R19, R29, R48). Findings include: 1. Review of R6's EMR, under the Profile tab showed that R6 was admitted on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance. Review of an annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 09/11/20 in the EMR under the MDS tab, showed a Brief Interview of Mental Status, (BIM) cognitive status of a score of 3 of 15, evidenced that R6 had severe cognitive impairment. The MDS assessment showed R6 had no broken or missing teeth, no broken dentures, and no mouth pain. Review of a quarterly MDS assessment with an ARD of 04/12/21 in the EMR under the MDS tab indicated R6 was not assessed for any dental pain or difficulty chewing. Review of Nursing Notes in the EMR under the Progress Notes tab and documentation in the paper medical record under…

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

Based on record review, staff interview, and observation, the facility failed to develop and implement a comprehensive care plan for one of 27 sampled residents (Resident (R) 6) reviewed for care plans. The facility failed to develop a care plan to address R6's dental status/missing teeth. Findings include: Review of R6's electrical medical record (EMR), under the Profile tab indicated that R6 was admitted with the diagnoses which included unspecified dementia without behavioral disturbance. Review of an annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/11/20 in the EMR under the MDS tab, showed a Brief Mental Status assessment score of 3 of 15 and evidenced severe cognitive impairment. The assessment showed R6 had no broken or missing teeth, no broken dentures, and no mouth pain. Review of a quarterly MDS assessment with an ARD of 04/12/21 in the EMR under the MDS tab indicated R6 was not assessed for any dental pain or difficulty chewing. R6 was observed on 04/21/21 at 9:21 AM, sitting in a wheelchair in her room. Attempts to interview R6 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.

Based on review of facility policy, record review, and staff interviews the facility failed to ensure for one of one resident reviewed for the use of side rails in a sample of 20 residents (Resident (R)3, that R3 had been assessed for the use of side rails, a physician's order had been obtained for the use of side rails, and a care plan developed with specific interventions for the use of the side rails. The assessment for the use of side rails indicated not needed, no physicians order was obtained and no care plan developed for R3. Findings include: The facility's Bed Safety Policy, undated, read, Our facility shall strive to provide a safe sleeping environment for the resident; and 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family's regarding previous sleeping habits and bed environment; and 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with 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 2. Resident #43 was placed on Seroquel (antipsychotic) 50 mg (milligrams) twice daily for dementia without behavioral disturbance. There is no appropriate diagnosis for use and the medication is associated with increased risk of death in the elderly with dementia. Additionally, there were no care plan interventions to address behaviors or for the continued use of an antipsychotic. Resident # 43 was admitted to the facility 3-4-17. Her diagnoses included but were not limited to: Stroke, dementia and hemiplegia. Resident #43's most recent MDS (minimum data set) with an ARD (assessment reference date) of 9-24-18 was coded as a quarterly assessment. Resident #43 was coded as having a BIMS (Brief Interview for Memory Status) Score of 9 out of 15 indicating moderate cognitive impairment. She was coded as needing extensive to total assistance of one staff member to perform her activities of daily living. Resident #43 was coded as requiring extensive assistance for eating. There were no behaviors documented for the 7…

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, facility staff interview, clinical record review, and facility documentation review, the facility staff failed for 5 Residents (Resident #23, #13, #28, #53, #43) in a sample of 26 residents to ensure they were free from unnecessary psychotropic medications. 1. For Resident #23, the facility staff failed to ensure he was free from the psychotropic medication Seroquel which is not indicated for residents with the diagnosis of dementia with or without behavioral disturbances. 2. For Resident #13, the facility staff failed to ensure she was free from the psychotropic medication Risperdal which is not indicated for residents with a diagnosis of dementia with behavioral disturbance. 3. For Resident #28, the facility staff failed to ensure that he was free of Seroquel, which according to the Black Box Warning, is not indicated for use in residents with Dementia-related psychosis. 4. Resident #53 was administered Seroquel (antipsychotic medication) without an appropriate supporting diagnosis. 5.…

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 an antibiotic stewardship program. The facility staff failed to monitor antibiotic usage and collect outcome data until June, 2018. The Findings included: On 10/12/18 at 9:33 A.M., a review was conducted of the facility's Infection Control Program. The Assistant Director of Nursing (RN A) stated that she started an antibiotic stewardship when she began working at the facility in June, 2018. The Director Of Nursing (Administration B) agreed. The Director of Nursing stated that the facility did not have any documentation that an antibiotic stewardship program was developed and implemented prior to June 2018. On 10/12/18 a review was conducted of facility documentation, revealing an Antibiotic Stewardship Policy dated December, 2016. It read, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices 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, facility staff interview, clinical record review, and facility documentation review, the facility staff failed for Resident #28 of the survey sample of 26 residents, to ensure the right to be informed of treatment risks, and alternatives of psychotropic medications. The facility staff failed to fully inform Resident #28's Responsible Party of the increased risk of death from Seroquel, and possible alternatives. The Findings included: Resident #28 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #28's diagnosis included Dementia with Behavioral Disturbance, Lobar pneumonia, Chronic Kidney Disease, Heart Disease, Type 2 Diabetes Mellitus with hyperglycemia, and Dependence on Renal Dialysis. The Minimum Data Set, an Annual Assessment with an Assessment Reference Date of 6/4/18, coded Resident #28 as not having any behavioral issues. On 10/12/18 a review of Resident #28's clinical record was conducted, revealing a care plan. It read, Problem onset: 6/4/18, receives…

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 obtain a Pre-admission Screening and Resident Review (PASARR) prior to admission for 1 resident (Resident #53) of 26 residents in the survey sample. For Resident #53, the facility did not receive or review the PASARR prior to admission. The findings included: Resident #53, a [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included Vascular dementia with behaviors, delirium, hypertension and hyperlipidemia. The most recent Minimum Data Set assessment was an admission assessment with an assessment reference date of 10/1/18. The resident had a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment. On multiple occasions, Resident #53 was observed seated near the nursing station sleeping in his wheelchair. Resident #53's PASARR was not located in the clinical record. On 10/11/18, facility staff were asked to provide the document. The document was provided the following day. 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 clinical record review, the facility failed, for one resident (Resident #35) in a survey sample of 26 residents, to complete a comprehensive care plan. 1. For Resident #35, the facility failed to devise a plan for patient-centered activities pertaining to the potential for sensory deprivation and isolation. The findings include: Resident #35, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses include hypertension, dementia, gastroesophageal reflux, dysphagia, contractures, and hypothyroidism. Resident #35 has bilateral above-the-knee amputations and receives tube feedings via gastrostomy tube. Resident # 35's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 09/10/2018. Resident #35 did not have a Brief Interview of Mental Status (BIMS) score recorded but cognitive skills for daily decision-making were coded as severely impaired. Hearing ability was coded minimally difficult and vision was coded as severely…

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 revise the care plan for 3 residents (Resident #56, #6, and #13) of 26 residents in the survey sample. 1. Resident #56's care plan did not address pain management. 2. The facility failed to revise the care plan and provide a bed alarm as ordered for Resident # 6. 3. For Resident #13, the facility failed to revise the care plan when the antipsychotic medication was initiated on 09/10/2018. The findings included: 1. Resident #56's care plan did not address pain management. Resident #56, a [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included hip and rib fracture, osteoarthritis, depression, diabetes, and hypertension. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 10/2/18. The resident was coded with a Brief Interview of Mental Status score of 13 indicating no cognitive impairment. She was coded to have frequent pain making it hard to sleep and limiting…

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, record reviews, and facility documentation, the facility failed to assess and provide on-going resident-centered activities for one Resident (Resident #35) out of a sample of 26 residents. Resident #35 was observed to be in his room for 3 days without getting out of bed and with no meaningful activities provided. In addition, between 07/02/2018 through 08/12/2018 the resident only attended two church services, a bible study, and two exercise sessions. The findings included: Resident #35, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses include hypertension, dementia, gastroesophageal reflux, dysphagia, contractures, and hypothyroidism. Resident #35 has bilateral above-the-knee amputations and receives tube feedings via gastrostomy tube. Resident # 35's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 09/10/2018. Resident #35 did not have a Brief Interview of Mental Status (BIMS) score recorded but 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.

Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to ensure the highest practicable well being for 1 resident (Resident #25) in a survey sample of 26 residents. Resident #25 did not have on her physician ordered TEDS (clot preventing/treatment of edema) stockings during the days of survey. The findings included: Resident # 25 was admitted to the facility 8-14-17. Her diagnoses included but were not limited to: high blood pressure, dementia and arthritis. Resident #25's most recent MDS (minimum data set) with an ARD (assessment reference date) of 8-21-18 was coded as an admission assessment. Resident #25 was coded as having a BIMS (Brief Interview for Memory Status) Score of 2 out of 15 indicating severe cognitive impairment. She was coded as needing extensive to total assistance of one staff member to perform her activities of daily living. On 10/10/18 at 12:58 PM: Resident #25 was observed in the dining room. There were no TED stockings in place. Review of the active physician's order dated 10-26-17 revealed 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 clinical record review the facility staff failed to provide toileting supervision and implement fall interventions for 2 residents (Resident #56, #6) of 26 residents in the survey sample. 1. Resident #56 required total dependence of one staff while toileting. She was observed alone on the toilet in her room. 2. For Resident #6, the facility failed to implement a bed alarm as a fall intervention. The findings included: 1. Resident #56 required total dependence of one staff while toileting. She was observed alone on the toilet in her room. Resident #56, a [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included hip and rib fracture, osteoarthritis, depression, diabetes, and hypertension. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 10/2/18. The resident was coded with a Brief Interview of Mental Status score of 13 indicating no cognitive impairment. She was coded to require total dependence…

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 implement a toileting program for 1 resident (Resident #56) of 26 residents in the survey sample. Resident #56 was not toileted every 2 hours as ordered. The findings included: Resident #56, a [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included hip and rib fracture, osteoarthritis, depression, diabetes, and hypertension. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 10/2/18. The resident was coded with a Brief Interview of Mental Status score of 13 indicating no cognitive impairment. She was coded to require total dependence of one staff person while toileting. It was coded that a urinary and bowel toileting program were being used. On 9/21/18, Resident #56 fell and broke her hip and ribs. She returned to the facility after a four day hospital stay. Some of the falls Resident #56 sustained at the facility involved the resident trying…

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 pain management for 1 resident (Resident #56) of 26 residents in the survey sample. Resident #56 expressed having pain but did not have pain management in place. The findings included: Resident #56, a [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included hip and rib fracture, osteoarthritis, depression, diabetes, and hypertension. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 10/2/18. The resident was coded with a Brief Interview of Mental Status score of 13 indicating no cognitive impairment. She was coded to require total dependence of one staff person while toileting. She was coded to have frequent pain making it hard to sleep and limiting daily activities. On 9/21/18, Resident #56 fell and broke her hip and ribs. She returned to the facility after a four day hospital stay. On 10/10/18 at 1:15 p.m., an interview 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 facility documentation review, the facility pharmacy failed, for 1 resident (#28) to report irregularities in monthly reviews. 1. For Resident #28 the facility pharmacy failed to identify a contraindication with Seroquel and Dementia. The Findings included: Resident #28 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #28's diagnosis included Dementia with Behavioral Disturbance, Lobar pneumonia, Chronic Kidney Disease, Heart Disease, Type 2 Diabetes Mellitus with hyperglycemia, and Dependence on Renal Dialysis. The Minimum Data Set, an Annual Assessment with an Assessment Reference Date of 6/4/18, coded Resident #28 as not having any behavioral issues. On 10/12/18 a review of Resident #28's clinical record was conducted, revealing a care plan. It read, Problem onset: 6/4/18, receives psychotropic medication due to diagnosis of psychosis. Psychosis is not an official diagnosis. Resident #28's care plan did not address dementia care and services. 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.